AD-A257 437

REPORT NO T13-92

CHANGES IN SOLDIER NUTRITIONAL STATUS &IMMUNE FUNCTION DURING THE RANGER TRAINING COURSE

U S ARMY RESEARCH INSTITUTEOF

ENVIRONMENTAL MEDICINENatick, MassachusettsD, LET I C -ýc, y•<

fobeoý ol~ypptovsd 0-g 5ltP"bjw £Ofels. and nae OPPOUTu 3 01992, L z , 0 13 u•,mite .. 92-28308

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USARIEM'.RESEARCH FOR THE SOLDIER

UNITED STATES ARMYMEDICAL RESEARCH & DEVELOPMENT COMMAND

Disclaimer

The views, Epinions, and/or findings contained in this report are those of the authorsand should not be construed as official Department of the Arnny position, policy, ordecision, unless so designated by other official documentation.

Human subjects participated in this study after giving their free and informedvoluntary consent. Investigators adhered to AR 7C-25 and USAMRDC Regulation70-25 on Use of Volunteers in Research.

Citations of commercial organizations and trade names in this report do notconstitute an official Department of the Army endorsement or approval of theproducts or services of these organizations.

Approved for public release; distribution is unlimited.

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ORIGINALDOCUMENT

Technical Report No. T13-92

CHANGES IN SOLDIER NUTRITIONAL STATUS& IMMUNE FUNCTION DURING THE RANGER TRAINING COURSE

CPT Robert J. Moore, Ph.D.1

MAJ Karl E. Friedl, Ph.D.2

Tim R. Kramer, Ph.D.sLTC Lester E. Martinez-Lopez, M.D.6

Reed W. Hoyt, Ph.D.3

Richard E. Tulley, Ph.D.7

James P. DeLany, Ph.D.8

COL E. Wayne Askew, Ph.D.1

James A. Vogel, Ph.D.'

1Military Nutrition Division, 2Occupational Physiology Division, and 'AltitudePhysiology & Medicine Division, 'Occupational Health and Performance Directorate,US Army Research Institute of Environmental Medicine, Natick, MA 01760-5007

$Vitamin and Minerals Laboratory, Beltsville Human Nutrition Research Center,US Department of Agriculture, Beltsville, MD 20705

6Department of Family Practice and Community Medicine,Martin Army Community Hospital, Fort Benning, GA 31905-6100

7Clinical Research Laboratory, aStable Isotopes Analysis Laboratory, PenningtonBiomedical Research Center, Louisiana State University, Baton Rouge, LA 70808

September 19032

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Clia~igcs in Soldier ~I'utritional Status & Immune Function during the Ranger Training Course (U)

12 PERSONAL AUTHOR(S) Moore, Robert J. ; Friedi , Karl E. ; Kramer, Tim R. ; Martinez-Lopez, LesterE.; fHoyt-, Reed W.; Tulley, Richard E.; DeLany, James P.; Askew, E._Wayne; Vogel, James A.13a TYPE OF REPORT lbTIME COVERED 14~ DATE OF REPORT ( Year, M~onth, Day) 115 PAGE COUNT

Ii i.,l I ROM..Ju.ne..91 TO J~an...2 I 1992 September 10 I 16216 SUPPLEMENTARY NOTATION

17 COSATI CODES I18 SUBJECT TERMS (Continue on reverse Ir necessary &And identify by block number)FIELD GROUP ISUB-GROUP nutrition, energy expenditure, energy intake, weight loss.

immune function, physical performance, medical problems,I jcellulitis, body composition, vitamins, clinical chemistry

1) ABSTRACT (Continue on reverse it necessatry end identify by block number) Prompted by several infectious diseaseep~idemics and the perception that weight loss was excessive, the US Army :)anger Trainingbrigade requested an assessment of tile effect of restricted rations on nutritional status,p~hysical performance, and immur.e function during summer Ranger training. A comprehensivephysiological evaluation of 55 volunteers who completed all 4 phases of the 8-1/2 wk course.ýas m~i(I at the beginning and end of the course, with abbreviated measurements made at theend (,f each 2 wk phase. Thu study revealed that Ranger students have a decreased protectioniagarI-st infection, with decreased T-lyniphocyte function. There was no evidence of avi tami n, mineralI, or proteirn defi Ciency dcspi te reduced rations, and extensive cl inicalcliemi stry profiles were remarkably noirmal, indicating that this is an uncomplicated energyd e fic ienc% . (average energy expenditure & intake: 4010 & 2800 kcal/day, respectively).We-(ight ]os~i was high (15.6%ý of weight) but recovery to original fitness levels occured by

f, rmonths after the end of training. It is concluded that as little as 300-400 kcal/dayi!!crease in intakes may attLernuiiLe decrements in physical performance and immune func~tion.A fol low-onl study of the effects of an intervention using the LLRP ratini rnsd20 DISTRIBUTION /AVAILABILITY OP ABSTRACT 21 ABSTRACT SECURITY CLASSIFICATION

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E

TABLE OF CONTENTS

Report Documentation Page (Abstract) ................................................................. iList of Figures .................................................................................................. ivList of Tables ..................................................................................................... viAcknowledgments ................................................................................................ viii

Sum m ary ................................................................................................................ 1

Preface .............................................................................................................. 5

INTRO DUCTION ............................................................................................... 7

M ETHO DS ....................................................................................................... 11

RESULTS & DISCUSSION

Medical attrition ................................................................................... 31Infection rates ...................................................................................... 35Body com position ................................................................................. 36

Strength m easurem ents ....................................................................... 47Energy expenditure and water turnover ................................................. 51Clinical chem istries .............................................................................. 53Vitam in status ...................................................................................... 61Endocrine responses ............................................................................ 66Delayed skin hypersensitivity test ........................................................ 69Cell-m ediated im m une function .......................................................... 70

CO NCLUSIONS ............................................................................................. 77

RECO MM ENDATIO NS ................................................................................... 81

References ....................................................................................................... 82

Appendix I Statement of the Problem (COL John J. Maher Ill)Appendix II Description of the Ranger course (portions of SH 21-75, Sept 1989) U

Appendix III Recommendations of the Committee on Military Nutrition .........................Appendix IV Summary of 6-month followup observations (Catherine E.

Harvey, Deborah Jezior & Elaine Christensen) ..........................

A I d:'d-i i orDist eci

LIST OF FIGURES

Figure 1. Estimated daily caloric intake based on the schedule ofprovided rations ............................................................................................. 16

Figure 2. Percent of soldiers attrited or recycled for academic and medicalreasons .......................................................................................................... . . 33

Figure 3. The prevalence of positive cultures of Group A ý-hemolyticStretptooi and Streptococcus Dneumoniae before and at the end of eachphase of Ranger training ................................................................................. 36

Figure 4. Distribution of the starting sample of Raager students by initialpercent body fat ............................................................................................. 37

Figure 5. Distribution of soldiers by weight loss (in pounds) during thecourse ............................................................................................................ . . 39

Figure 6. Distribution of soldiers by weight loss (as percent of initial bodyweight) during the course .............................................................................. 39

Figure 7. Body weight and sum of four skinfold thicknesses ofnonfinishers still remaining in the Ranger course at the end of eachtraining phase, compared to finishers ................................................................. 40

Figure 8. Distribution of finishers by percent body fat at the start of theRanger course, at the end of the third phase, and at the end of the course ..... 41

Figure 9. Fat weight of individuals ranked by initial fatn6ss, showing thefat lost in the first 3 phases and additional fat lost in the last ph3se oftraining, and relative changes in FFM for the same individuals .................... A2

Figure 10. Skinfold thicknesses measured at the beginning and end of eachphase of training ........................................................................................... . . 43

Figure 11. Relative change in circumference me, cements made at theend of each phase of training, compared to startin, neasurements ............ 44

Figure 12. Mean weights of key components of body composition at thebeginning of training and at the end of phases III & IV ................................. A4

Figure 13. Distribution of maximal lift performance at the beginning andat the end of Ranger training ......................................................................... 47

iv

Figure 14. Relationships between FFM and grp strength and maximal liftat the start of the course, and changes in FFM and changes in gripstrength and maximal lift through the course ................................................. 48

Figure 15. Total daily energy expenditure and estimated food energyintake over the course of Ranger training ...................................................... 51

Figure 16. Energy balance during Ranger training ....................................... 52

Figure 17. Estimated total water turnover during the four phases of theRanger training course ................................................................................... 53

Figure 18. Iron balance and related hematological parameters duringRanger training ............................................................................................... . 54

Figure 19. Serum cholesterol subfraction levels at the beginning and endof each phase of training ................................................................................. 57

Figure 20. Serum vitamin concentrations at baseline and at the end ofeach phase of Ranger training ....................................................................... 63

Figure 21. Erythrocyte folate concentrations and erythrocyte enzymestimulation tests at baneline and at the end of each phase of Rangertraining .......................................................................................................... . . 64

Figure 22. Declining serum testosterone and LH levels are indicators of agenGralized stress response; increasing SHBG levels reflect the caloricdeficit ............................................................................................................ . . 66

Figure 23. The changes in mean serum levels of IGF-1, growth hormone,and triiodothryronine reflect normal responses to a prolonged energy deficit .... 67

Figure 24. Proliferative activity of lymphocytes collected through thecourse and stimulated with pokeweed mitogen, phytohemagglutinin,concanavalin A, and tetanus toxoid in vitro ................................................... 71

Figure 25. Changes and recovery of 3 aspects of in vitro phytohematgglutininstimulated T-lymphocyte response: IL-2 receptor secretion, IL-2

secretion, and proliferation .............................................................................. 73

Figure 26. Production of IL-6 in unstimulated whole-blood cultures andplasma levels of IL-6 in samples collected through the course ..................... 74

v

LIST OF TABLES

Table 1. Baseline descriptive data of soldiers starting and completingR anger training ............................................................................................... . 13

Table 2. Calendar, temperature, relative humidity, precipitation, andration schedule for Ranger Class 11-91 ........................................................ 14

Table 3. Measurements made at each period ............................................... 17

Table 4. Experimental design for energy balance and water turnoverstudies .......................................................................................................... . . 2 1

Table 5. Measured blood-borne biochemical markers of vitamin andiron status ..................................................................................................... . . 2 4

Table 6. Cell culture conditions for immune function studies ....................... 28

Table 7. Success rate by pre-Ranger training origin ..................................... 31

Table 8. Reasons for class attrition at each phase of Ranger training ........ 32

Table 9. Reasons for course attrition, as in Table 8, except without thoserecycled soldiers who graduated in the next 2 classes ................................... 34

Table 10. Infections documented in medical records which were

treated with antibiotics during the last 3 phases of training ........................... 35

Table 11. Body composition of soldiers during the Ra;,ger training course ...... 45

Table 12. Anthropometric measurements of soldiers during the Rangertraining course ............................................................................................... . 46

Table 13. Measurements of physical performance of soldiers during theRanger training course .................................................................................. 49

Table 14. Comparison of physical changes during Ranger training forsoldiers who lost >10% FFM and <4% FFM ................................................. 50

Table 15. Serum iron and ferritin levels, total iron-binding capacity,% iron saturation, red blood cell count, hematocrit and hemoglobin duringthe Ranger training course ............................................................................ 55

vi

Table 16. Serum enzymic markers of hepatobiliary and muscle metabolismof soldiers during the Ranger training course ................................................ 56

Table 17. Serum mineral and electrolyte concentrations in soldiers duringthe Ranger training course ............................................................................ 58

Table 18. Serum indices of energy and nitrogen metabolism in soldiersduring the Ranger training course .................................................................. 59

Table 19. Serum cholesterol and triglyceride levels in soldiers during theRanger training course ................................................................................... 60

Table 20. Estimated average daily nutrient intake over the entire courseand during FTX days with only a single MRE per day .................................. 61

Table 21. Indices of Vitamin A, C, D, B12, B6, folate, thiamin, and riboflavinstatus in serum and erythrocytes of soldiers during the Ranger course ..... 62

Table 22. Indices of Vitamin A, C, D, B12 , B6 , folate, thiamin, and riboflavinstatus in sorum and erythrocytes of soldiers who used no supplementsduring the Ranger course .............................................................................. 63

Table 23. Stress hormone levels in soldiers during the Ranger trainingcourse ........................................................................................................... . . 68

Table 24. Delayed type hypersensitivity skin test responsiveness atbaseline and at the end of jungle arnd desert phases .................................... 69

Tab!e 25. Complete and differential blood cell counts of soldiers duringthe hanger training course .............................................................................. 74

vii

ACKNOWLEDGMENTS

We are greatly indebted to the soldiers who volunteered to participate in this study overand above the requirements of Ranger training.

We are grateful to SSG Glenn Thomas and Ms. Elaine Christensen for their expertorganizational and technical work which made this study a success. Other members of the fieldstudy team included Mr. Lou Marchitelli, Mr. Peter Frykman, SPC Michael Johnson, Mr. RobertPetrin, SGT Kong Ang, MAJ Barry Fairbrother, SGT Marion Shelby, Mr. Jeff Tate, SPC SonyaMoore-Shelby, Ms. Kate O'Brien, and SPC Sherryl Kubel. MAJ O'Del!, C, Nursing, Cutler ArmyCommunity Hospital, Fort Devens generously augmented our field phlebotomy team. Dataanalysis support was provided by Ms. Bonnie Beam, Mr. John Finn, and Ms. Brooke Cheema.We thank LTC Robert Burr, M.D., for conducting physical examinations for nutritionaldeficiencies at the end of Ranger training. Dr. Claire C. Gordon, from the Science & AdvancedTechnology Directorate, US Army Natick Research, Development & Engineering Center, verykindly advised us on the expedient anthropometric measurements used in this study andprovided direct support of the study by Mr. Robert Petrin, research anthropologist.

This study required more than 10,000 biolc-.qical specimen analyses. The technical staffof the Clinical Chemistry Laboratory at Pennington Biomedical Research Center had the largestworkload and still produced a high quality and timely analysis. Mr. Lou Marchitell;, at USARIEM,singlehandedly performed all of the endocrine assays for this study and managed a largeportion of the database. We received excellent microbiology and hematology support from CPTJames M. Camp (Martin Army Community Hospital), CPT Daniel H. Atchley (Eglin Hospital), andMAM Hugh M. Gelston, Jr. and 1 LT Carmen D. Hernandez (Win Beaumont Army Medical Ctr).

This line of investigation was initiated because COL Thomas I. Clements (TRADOCCommand Surgeon) requested an EPICON meeting at the Ranger school and encouragedUSARIEM involvement. This study was only made possible because COL. John J. Maher III(Commander, Ranger Training Brigade) recognized the usefulness of the Army's medicalresearch services in improving his organization. Several members of the Ranger Trainingschool directly contributed to the success of this study, notably LTC Clyde M. Newman, CPTRennie M. Cory and SSG Charles R. Judd, in the first phase, and MAJ Pat Walsh and SSGTroy S. Glassman, in the last phase; they were Rangers who "made it happen." Other unknownmembers of the school cadre ensured samples and data were collected at appropriate timesand forwarded to our research team.

The results of this study were briefed to the Ranger Training Brigade (COL Maher, 9 Jan92), Medical Research & Development Command (MG Travis, 21 Feb 92), The SurgeonGeneral of the Army (LTG Ledford, 27 Mar 92), and the DOD Food and Nutrition Research andEngineering Board (13 May 92). The results were also presented to and reviewed in depth bythe National Academy of C.ciences' Committee on Military Nutrition Research, including severalspecial consultants (Per !,,istian Opstad, M.D., Norwegian Defence Research Establishment;John M. Kinney, M.D., The Rockefeller University; William R. Beisel, M.D., Johns HopkinsSchool of Hygiene and Public Health; Walter Merz, M.D., U.S. Department of Agriculture,Beltsville; Thomas R. Ziegler, M.D., Harvard Medical School). The conclusions andrecommendations of the Committae are included at Appendix Ill.

Finally, the support and encouragement of USARIEM Commander COL Gerald P.Krueger and USAMRDC Research Area III Director COL David D. Schnakenberg wasinstrumental in accomplishing this study.

viii

SUMMARY

During Ranger training soldiers lose more body weight and suffer relativelyhigher rates of infection compared to soldiers undergoing less rigorous field training.The relationships between restricted food intakes, sleep deprivation, mental andphysical stress with body weight loss and susceptibility to infection of Ranger studentshas not been studied. Recent episodes of pneumococcal pneumonia among Rangerstudents resulted in a request from the Commander of the Ranger Training Brigade fora scientific investigation which would be a first step in addressing the relationshipbetween the nutritional status, body weight loss, and i-nmunocompetence of soldiersundergoing Ranger training.

Soldiers from a single Ranger training class (conducted from July throughSeptember 1991) were studied; 190 students began the study, and 55 soldiers fromthe original cohort completed all phases of the 62-day course. A comprehensivebattery of physiological, physical performance, and immunological measurements weremade at the beginning ano end of the course, with more limited sampling conducted atthe end of each two-week phase. The four training phases were: Phase I, temperateforest (Ft. Benning/Camp Darby, Georgia), Phase II, mountains (Camp Merrll,Georgia), Phase Ill, jungle (Camp Rudder, Eglin AFB, Florida), and Phase IV, desert(Ft. Bliss, Texas). On 35 of the 62 days of the course, students were provided asingle meal (equivalent to one MRE/day; 1300 kcal). Samples and measurementswere taken to determine: 1) changes in body weight and the composition of bodyweight loss, muscular strength, and muscular endurance, 2) energy expenditure,3) nutritional sWatus (biochemica! assessment of protein/calorie, vitamin, and mineralstatus', 4) in vitro and in vivo cellular immune function, and 5) the incidence ofinfe,-tian, injuries, and 3ther medical problems.

Attrition. Of the odginal sample of 190 students, end-of-course measurementswere made on 55 students (29%) but only 33 students (17%) met all courserequirements and graduated ir. a single pass. Additional members of the study groupwere recycled into subsequent classes, resulting in 90 students (47%) eventuallygraduating to earn the Ranger tab. From the orginal sample, 40 students (21%) wererecycled or dropped from the course for medical reasons.

Chanqes in body composition & physical performance. Students lost an

average of 15.6% (range: 9-23%) of their body weight (11.8 kg) and body fat declined

1

from 14.6% (5.7-26.1%) to 5.8% (4.4-11.9%); thus, fat loss represented 61% of thetotal weight loss and this loss reduced estimated available fat stores by more than90%. Fat-free mass losses averaged 4.6+2.6 kg (6.9+3.6% of initial values). Sincemost of this represents loss of muscle tissue and muscle mass represents only abouthalf of the fat-free mass, it can be estimated that most students lost greater than 10%of their muscle tissue. There was no significant loss of bone mineral. Isometric gripstrength and grip holding endurance (60% of maximum grip strength) were notsignificantly changed during the course, but a maximum lift strength declined from 77kg to 59 kg during the course. Soldiers losing the most muscle mass suffered thelargest decrements in lift strength.

Enerav expenditure & water requirements. Average daily energy expenditurewas 4010 kcal/day. Energy expenditure was variable during the course, ranging from3150 kcal/day during the early desert phase to over 6000 kcaVday during themuuntain phase. The daily energy expenditures were met by approximately 2800kcal/day from food and 1200 kcal/day from body energy stores; thus, there was a netenergy deficit of 31% produced by periodically restricted rations. The largest relativeenergy deficits were observed during the mountain (37%) and jungle phases (33%),while a more modest relative energy deficit was seen during the desert phase (15%).The lower deficit during the desert phase largely reflected higher food intakes duringthe pre-FTX portion of the phase. Estimates of water turnover for each of the fourphases were 8.5, 6.1, 6.8, and 5.0 liters/day.

Nutritional assessment. Biochemical markers of protein/energy metabolism,and of selected vitamins and minerals were determined in tasting blood samplescollected initially and at the end of each training phase. The results indicate that noovert vitamin or mineral deficiencies were present at sampling times, regardless ofwhether students were using vitamin/mineral supplements. This suggests that dietand body stores provided sufficient vitamins and minerals to meet metabolicrequirements, even during periods of reduced nutrient intakes. Most indicators ofmetabolism (e.g. glucose, serum protein, albumin, 3-hydroxybutyrate, fatty acids, ureanitrogen) remained within normal limits. There was a transient decline in glucose andrise in urea nitrogen during the course, indicative of an increase in protein catabolism.Nutrient intakos. averaged for the entire 62-day period, met the MRDA for mostnutrients, ey';6pt for energy. Large and consistent declines in hormonal markers suchas insuin-like growth factor-I, tiiodothyronine, and testosterone support theconclusion that the major nutritional insult of the Ranger course is sustained energy

2

deficit, although the data cannot rule out the occurrence of periodic metabolicdeficiencies of specific amino acids, vitamins or minerals during the periods of mostsevere food restriction.

Cellular immune function. Immune function was reduced by the end of the firstphase, with the greatest and most uniform impairment at the end of the mountainphase (week 4), followed by a partial recovery at the end of the desert phase (week 8-1/2). This recovery coincided with the period during which the smallest energy deficitexisted. Reduced T- and B-lymphocyte proliferation In response to mitogen exposuresuggests that resistence to infectious agents was reduced to the greatest extentduring the mountain and jungle phases; reduced plasma concentrations and cellularproduction of intereukin-6 after the jungle phase suggests an Impairment in the abilityof the immune system to recruit assistance In controlling inflammation and Infection.

Medical problems. Infection rates increased from 8% of the class during themountain phase to 25% of the class during the jungle and desert phases. Theinfections were primarily soft-tissue infections (cellulitis), most often affecting theknees. Aggressive treatment with antibiotics by medical personnel was a likely reasonthat medical attrition from this class was not higher. The number of students Identifiedas carriers of Group A beta-hemolytic Streotococcus remained low throughout thecourse, but Streptococcus Dneumoniae carriage rates increased to 12% of the classby the jungle phase.

The weight loss was substantial in this group of soldiers. Although a largeportion of the energy deficit was compensated for by utilizing fat stores for energy, asignificant amount of fat-free mass was also lost. The Ltonsequence of this loss ofmuscle mass was manifested in a 23% decrease in lifting strength. Most soldierswere able to maintain blood-borne markers of nutritional status within normal limitsthroughout the course. A significant finding was the dramatic suppression in cellularimmune function which occurred in the course, and the observation that thesuppression coincided with the periods of highest infection rates. There was a partialrecovery in cellular immune function at the end of the course, which coincided with aperiod of refeeding and a reduction in the magiitude of the energy deficit. The resultsof this study suggest that the high levels of energy expenditure coupled with restrictedfood supply during Ranger training increase the risk of susceptibility to infection.

3

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�ij�B'

PREFACE

This report emphasizes the nutritional stress of Ranger training. However,

Ranger training is a multistressor environment also encompassing high energy

expenditure, sleep deprivation, anxiety, heat or cold depending on the time of year

(ours was R summer Ranger class), and other stressors such as blistered feet and

infection. A stressful environment is a critical aspect of the course, where soldiers are

evaluated for their ability to set aside their basic needs in order to lead their patrol and

accomplish the mission. The school has control over two key stressors, food and

sleep deprivation, and these are probably the most important aspects of the

suppressed immunocompetence and loss of weight which we report here. Anxiety

about success in the course is not likely to play a large role because there is littleroom for it on top of sleeplessness and hunger and because soldiers know that as

long as they are still in the course they are still succeeding; in any case, this is not

greater in magnitude than would be experienced in other Army courses.Manifestations of many of the other stressors (e.g. cold sensitivity, upper limits of

energy expenditure) are integrally linked to food deprivation. The stress responsesmeasured in this study reflect primarily sleep and energy deficits. The influence of

sleep deprivation was not evaluated in this study, making it difficult to separate theindividual and additive effects of these stressors on immune function. We believe that

relatively small improvements in sleep time and/or energy deficit may attenuate the

immune function decrement we observed.

The results of the classic Minnesota starvation-refeeding study (1) provide the

closest comparison to this study because of the high weight losses resulting from low

energy intakes. However, there are some significant differences between our study

and the Minnesota study. The Minnesota study was designed to replicate starvation

conditions and examine refeeding strategies for individuals experiencing famine andstarvation at the end of WWII. That study was also performed with healthy youngmale volunteers on restricted rations. However, ration restriction was continuous andwas the only deliberate stressor in otherwise sedentary men. In contrast, the soldiers

in our study had brief refeeding opportunities at the beginning of each 2-week trainingphase and they remained very physically active even during periods of caloric

restriction. A second difference is that volunteers in the Minnesota study were pushed

to a greater weight loss (individual goal 25% of body weight) than our Ranger

student volunteers (average weight loss = 15.6% of body weight). There are

appropriate physiological responses, such as the sacrifice of fat mass over lean and a

5

reduction in resting metabolic rate, which protect and optimize physiological function inthese conditions. However, with a continued energy deficit carried to its extreme,there is no adaptation which prevents death when carded to its extreme; the soldiersin our study were in an early part of this continuum. They used nearly all of theiravailable fat supplies but, unlike the Minnesota Study, were only just beginning tocatabolize portions of their lean mass. Thus, Ranger students are physiologicallychallenged with energy deprivation but they have not been pushed Into the category ofemaciation which would describe the semi-starved volunteers in the MinnesotaStudy.1

This study addressed specific q ;Fi posed to us by the Ranger TrainingBrigade Commander. Because of the ;pfciai Anvironment of the Ranger trainingprogram, the extremely strenuous training, and the importance of this course tomilitary careers of the volunteers who compete to attend, we could not design thestudy to control all experimental variables that woild normally be controlled in ascientific study on exercise, food and sleep deprivation, and weight loss. With thisstudy we have been able to describe the very interesting physiology of Rangertraining. As a consequence of our findings, some aspects of this training have alreadybeen changed and thus our description represents an earlier baseline which is insome respects already obsolete as a description of Ranger training. This study ishighly relevant in that it may have produced a better and safer training course byquantifying nutritional stress limits which should not be duplicated or exceeded. Inaddition, a well planned applied study can usually lead to new understandings of basicmechanisms. This study demonstrated the remarkable ability of the body to

accommodate a severe caloric deficit, with clinical chemistries remaining within normallimits even as the lower end limits of body fat were achieved; this degree of weightloss has been usuilly studied only in sick patients with other complicatingcharacteristics.

'Even so, the Commander of the Ranger Training Brigade determined that an average

v/eight loss of 15% of body weight is too much, relative to the goals of Ranger training,ai.d he adopted changes in the ration schedule within 24 hours of the initial outbrief ofresults of this study.

6

INTRODUCTION

The US Army Ranger Training Course is a demanding 62-day training program

designed to teach and evaluate individual leadership and small unit tactics underphysically and mentally demanding conditions. The course subjects trainees tomultiple stressors including restricted food availability, sleep deprivation, and periodsof sustained physical exertion, as 7-10 day periods of simulated combat patrols, indiverse climatic and terrain environments.

A Ranger class typically experiences an overall attrition rate of 50-60%.Approximately one-half of the attrition (25-30% of the original class) has beenattributed to illness or injury (2). Additionally, many Ranger trainees receive medicaltreatment for other injuries, illnesses, and infections but are subsequently removedfrom the course for non-medical reasons, or complete the course in spite of theillness. Ranger training poses a significant medical threat to the trainee because ofthe low food intake, sleep deprivation, high energy expenditures, and limitedopportunities for personal hygiene.

The ration provisions, sleep regimes, and training tasks in the Ranger trainingschedules are designed to create a high-stress environment which permits realisticevaluations of trainee ability without subjecting them to unnecessary health risks. Inearly 1991, a Ranger class experienced a significant outbreak of pneumococcalpneumonia (3). Fourteen cases (6% of the class) were diagnosed as clinicalpneumonia and over 33% of the trainees were identified as Streptococcuspneumoniae carriers, with 91% of the carriers reporting cough or rhinorrhea. Theseobservations indicated that Ranger trainees exhibited a higher S. pneumoniae carriagerate than the general population, yet it was unclear if the higher rate resulted fromgreater environmental exposure, or reflected an impaired ability to resist chronic oracute exposure to infectious agents. This pneumonia outbreak raised concerns thatthe multiple stressors associated with Ranger student training, specifically the reducedfood intake and accompanying body weight losses, might be contributing to anunacceptably high susceptibility to illness or injury.

Since the inception of the Ranger training program during World War II, therehas never been a systematic study of the impact of the program on Ranger health orsusceptibility to disease. There have been studies conducted which have documentedsome of the physiological consequences of the course on trainees (4,5). A survey of

7

the Ranger course in 1976 (4) indicated that trainees lost an average of 15 pcunds(9.4% of body weight) over the length of the course, with some soldiers losing asmuch as 17% of body weight. Most of the weight loss (57%) was body fat, but fat-freemass (5%) and water (38%) were also lost. These findings correspond with anecdotalreports from Ranger course graduates of body weight losses between 20 and 40pounds. However, a recent study (5) reported that Ranger trainees only lost 8.5pounds (5% of body weight) during the course, and that body fat content did notchange.

Previous studies with Ranger trainees showed that soldiers consumedapproximately 4000-4400 kcal per day when provided hot, prepared meals in a mess-type facility (4,6). However, a menu analysis of the 1989 Ranger feeding plan showedthat soldiers were provided only 2400 kcal/day during the first 6 days of a summerRanger training course (LTC Madeline S. Rose, unpublished results). During the 50days of field training when trainees conduct combat patrols, the students are givenrations which provide an average of less than 1500 kcal/day. Daily energyexpenditure was about 4000 kcal (range 3200-5200 kcal/day)(4,6). If calorie intakesare estimated at 1400 kcal per day during FTX patrol phases (50 days) and 5000 kcalper day (18 days) during garrison training, a weight loss of apDroximately 30 poundscan be predicted.

The impact of the amount of food restriction and accompanying weight loss inthe Ranger course on physical performance or physiologic function cannot bepredicted from the available information. Feeding studies conducted with soldiersduring field training exercises have shown that self-selected food intakes of 2000-3000kcal daily produce weight losses of 5-10% of body weight (7-9), and are notaccompanied by significant decrements in physical or mental performance. Thesedata indicate that mild to moderate weight losses pose a minimal risk to the soldier,however, these studies have only been conducted for relatively short durations (lessthan 30 days) and have not included additional stressors such as sustained sleepdeprivation, heavy physical work, etc.

Weights losses of less than 10% of body weight which occur in fewer than 10days do not appear to be associated with performance decrements, as long assoldiers receive sufficient water and energy (approximately 1500 kcal per day) toprevent dehydration, hypoglycemia, and ketosis (10,11). Although field studies haveshown that intakes of some minerals and vitamins are below the Military

8

Recommended Dietary Allowances (12), biochemical indicators of nutrient status havenot detected any functional consequences of the reduced nutrient intakes (7-9, 13).Studies of the Norwegian Rangers have shown that during intense, 5-day fieldexercises, blood levels of stress-induced catabolic hormones (testosterone, estradiol,cortisol) can only be partly returned toward norma! levels by increased calorie intakes(14-16). The physiological and nutritional consequences of prolonged caloriedeprivation coupled with the high energy expenditures of the Ranger Training Courseare not known, and it is not possible to predict whether an increase in calorie orspecific nutrient intakes would reduce the large weight loss associated with the course.

While we know that protein/calorie malnutrition and single nutrient deficienciesimpair in vivo and in vitro markets of i:imlmnocompetence (17-19) and can increasethe incidence of nosocomial infections in certain populations (20-21), nocomprehensive data are available which describe these changes in soldiersundergoing Ranger training. Thus, it is not possible to determine if the reduced foodintake and accompanying weight loss is of sufficient severity to increase the

susceptibility of the Ranger trainee to infectious disease, and if so, what wouldconstitute an appropriate nutritional or non-r-'tritional intervention to correct thecondition.

At lh": Invi•ation of the Ranger SchoQ, Commander (Appendix I), the present

study was roducted to provide a longitudina! description of the nutritional andphysiological impact of the Ranger course on the trainees. Blood and physiologicalmeasurements were collected to: 1) assess nutritional status by the measurement of

specific blood-orome biochemical indicators of nutritional status, 2) examine changesin body composition and muscular strength and endurance, and 3) assess in vitro andin vivo immune function.

9

'p

METHODS

RANGER TRAINING COURSE DESCRIPTION

The Ranger training course (22) is a 62-day training program which exposessoldiers to four different tactical and climatic environments: 1) Phase I: temperateforest, conducted at Camp Rog, s and Camp Darby at Fort Benning, Georgia,2) Phase I1: forested mountains, conducted at Camp Merrill, Georgia, 3) Phase II:coastal swampijungle, conducted at Camp Rudder, Eglin Air Force Base, Florida, and4) Phase IV: desert, conducted at Fort Bliss, Texas. Each phase is about 14 days induration, and includes an introductory training period (3-7 days duration) of classroomand field instruction of techniques and skills unique to the particular environment,followed by intensive 7-10 day simulated combat patrols away from the installation.A detailed course decription is in Appendix Ii.

Prior to beginning the course each prospective Ranger trainee must completethe Ranger Assessment Phase (RAP), which is conducted on the four daysimmediately before Phase I. On RAP day 1, trainees take a physical fitness test (asdescribed in AR 350-15)(23), meeting the 80% standard for 18 year olds, and with theaddition of pullups) and the Combat Water Survival Test; on RAP day 2, traineescomplete a morning 5-mile run (8:00 minute per mile pace) in shorts and runningshoes and an afternoon 8-mile road march with weapon and 35 pound rucksack load(initial 15:30 minute per mile pace gradually reduced to 20:00 minute per mile pace);on RAP day 3, trainees complete day and night land navigation courses; on RAP day4, subjects retake land navigation (if not passed on day 3) and take a series of militaryskills tests (passing 32 of 36 tasks as described in Appendix 11)(24).

Students are given several opportunities to repeat and pass the courserequirements before being dropped from the course. Soldiers with an academic ormedical problem can be recycled within a phase if it is determined by the trainingcamp commander, or by the Physician's Assistant, that the respective problem can berehabilitated in time for the soldier to continue with the next class, 30 days later. Moreserious problems lead to a drop from the course and a soldier who returns later mustrepeat the whole course.

11

TEST SUBJECTS

This study was reviewed and approved by the USARIEM Human Use ReviewCommittee, the Human Use Review Office at USAMRDC, and was conducted inaccordance with USAMRDC Reg No. 70-25 and AR 70-25 (25). All participants in thestudy were volunteers, and were recruited from class 91-11. All students were briefedon the purpose and aims of the study on or prior to RAP day 1. After being briefed,volunteers were required to read and sign a Volunteer Agreement Affidavit, certifyingthat the procedures of the study had been explained to them and ackncwledging thatthey could leave the study at any time withcut any adverse consequenc9s.

The original study population consisted of 190 male voluntee: s out of 261members of class 91-11. Fifty-five soldiers finished the course and were available formeasurements, however, only 33 soldiers successfully completed all courserequirements and graduated at the end of the course. Attrition during the RAP wasnot different between the test volunteer subset (35.8%) and the entire class (33.3%).Descriptive data for the initial test volunteer population and the population of traineeswho completed the course are presented in Taole 1.

EXPERIMENTAL DESIGN

The experiment was designed to collect longitudinal data on trainees at eachphase of the course. An experiment time line is presented in Table 2, which includesthe location, weather data, ration provision schedule, and subject measurement dates.Daily caloric intake estimated from this ration schedule is illustrated in Figure 1. Noother food was permitted in this course and violation of this rule was enforced withimmediate dismissal for an adverse Special Observation Report (SOR). Baseline datawas collected on all bainees prior to beginning the course, and then at the completionof each training phase. Specific methods will be discussed in detail in subsequentsections, but the following section provides an overview of the data collectionprocedures.

Specimens and data were collected five times during the course to assessnutrtional status, body composition, muscular strength and endurance, and immunefunction: baseline and at the end of each of the four training phases described earlier.Although all four general areas of interest were evaluated, not every measurementwas made at each data collection point. The specific measurements made at each

12

Table 1. Baseline descriptive data of all soldiers starting and soldiers completing

(Finishers) Ranger training. There were no statistical differences between groups.

All Soldiers Finishers

Item' n=190 n=55

Age, years 24.3+3.8 23.6+2.8(18-41) (18-31)

Weight, kg 76.6+9.2 75.9+8.9(46.4-106.6) (63.2-99.8)

Height, cm2 176.2+6.9 176.6±6.2(144.7-191.6) (165.4-191.6)

S)dy fat, %3 14.8+4.4 14.6+4.2(5.4-28.0) (5.7-26.1)

Ethnicity, numberNon-hispanic white 149 (78%) 44 (80%)Black 19 (10%) 4(7%)Hispanic 13 (7%) 5 (9%)Asian 4 1Native American 1 1Other 4 0

Military RankE2-E4 80 (42%) 26 (47%)E5-E7 40 (21%) 9 (16%)01-02 62 (33%) 20 (36%)03-05 8(4%) 0

Tobacco users, numberCigarettes 35 (18%) 6(11%)Smokeless 67 (35%) 20 (36%)

Coffee users, number 54 (28%) 16 (29%)

'Mean+standard deviation (range), or count (percent of total sample).2Crotch height, arm span, and sitting height were also not significantly differentbetween finishers and all soldiers; however, crotch height of Ranger studentsaveraged 86.3+4.6 cm, putting them at the 70th percentile for Army men (26),suggesting that long-leggedness may be a discriminating trait in these volunteers.3Body fat determined by dual energy x-ray absorptiometry (DEXA).

13

Table 2. Calendar, Temperature (T), Relative Humidity (RH), Precipitation (Piectp),and Ration Schedule for Ranger C:ass 11-91

Date Phase T RH Precip Ration Schedule(max/min) (max/rain)

(cF) (%) (inches) Breakfast Lunch Dinner

July 26 1 84/70 78/59 .07 MRE MRE MRE27 86/59 81/57 .02 A MRE MRE28 85/70 81/55 .04 A MRE MRE29 89/71 81/50 A MRE A30 87/70 81/57 A MRE MRE31 86/69 79/53 A MRE MRE

August 1 85/70 73/53 .05 A MRE A2 87/68 78/48 A MRE MRE3 91/70 78/78 Trace A4 91/71 79/50 MRE5 94/71 79/37 MRE6 93/71 78/44 S7 90/70 78/47 A8 92/70 78/42 MRE9 92/7.1 76/44 .14 MRE

10 88/72 73/49 .28 MRE A A11 A12 70/56 na .28 A B13 71/57 na .27 A A14 75i63 na .46 P. B15 85/54 na B A16 78/60 na A A17 81/58 na A A18 82/60 na .20 A A19 85/68 na .37 A20 90/67 na MRE21 80/60 na .70 MRE22 82/60 na MRE23 84/64 na24 86/63 na .7025 84/60 na .90 MRP_26 86/61 na .02 M,-E27 MRE A A28 111 89/76 97/56 No meals served29 90f75 96/55 .25 A BOX A

14

Table 2. (continued)

Date Pnase T RH Precip Ration Schedule(max/mir.) (max/min)

(OF) (%) (inches) Breakfast Lunch Dinner

30 85/74 76/71 .42 A MRE31 88/72 97/67 Trace MRE MRE

Sept 1 90/75 94/54 MRE MRE2 92/74 97/47 .12 A3 88/73 97/57 .Ob MRE4 86/73 90/59 MRE5 86/73 94/70 .14 MRE6 69/75 97/53 MRE7 91/74 94/47 Trace MRE8 88/73 93/61 A9 90/74 87/33 MRE

10 89/69 83/51 MRE11 89/71 90/51 MRE12 93/75 87/51 A BOX A13 IV BOX14 83/54 na A MRE B15 8C!45 na A MRE B16 88/45 na A MRE MRE17 92/52 na A MRE B18 92/49 na A MRE B19 79/47 na MRE20 83/44 na MRE21 83/5C na MRE22 79/58 na MRE23 77/51 na .,RE24 73/61 na MRE25 77/47 na MRE26 78/42 na MRE MRE A

notes: "S" denotes a survival meal comprised ot a live rabbit or chicken and somevegetables shared between Rangar buddies; "A" rations are hot meals prepared in afood service facility; "B" rations are hot meals prepared from nonperishable items;Meal, Ready-to-Eat (MRE) rations are individual meals th&t can be eaten hot or coldand are intended for use during operations that preclude organized food servicefacilities; Box lunches (BOX) are individual meals usually composed of a sandwich,potato chips, fruit ano a cold drink; for intake estimation purposes, an extra A rationhas been added between each phase (10 Aug, 27 Aug, 12 Sep) when trainees wererelgased on break for several hour.; and were permitted food ad libitum; na = data not available.

15

Estmated caloric intake (kcal/d *1000)6 Mountains 4Jungle • • "n ,

5 . .. . . ... . . . . .. . . . . .. . . .4, ,,,I , l ... .. .. .. .. ... .. .....2 . . . . ........

29 1 15 1 1525August September

Figure 1. Estimated daily caloric intake based on the schedule of provided rations.

collection point are listed in Table 3. Measurements were made on subjects between0430-0900 hours (except as noted below for baselino measurements). Volunteersreportr~n (as units) to the data collection area within 4 hours of returning from all-nightmissions. In all cases, measurements were made on volunteers before theyconsumed any meals following their return from the field.

IDENTIFICATION AND QUANTIFICATION OF ATTrRITION

All causes for soldier withdrawal from the Ranger training course were identifiedand grouped into four primary categories: medical, academic failure, voluntarywithdrawal, and administrative removal. For medical withdrawals, a diagnosis wasobtained from the medical records. At the end of each phase (starting with phase II),the medical treatment provided to students was obtained by raviewing all medicalrecords initiated by the Physician's Assistant during the training phase. Additionally,subjective observations on the general condition of the soldiers were made at the endof each phase while each soldier was completely disrobed. Non-medical reasons forwithorawal from training were obtained from the Ranger training cadre.

16

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Reasons for academic withdrawal included failing a majority of graded patrols,receiving an unsatisfactory peer rating from the other 11 squad members, receiving allexcessive number of negative spot reports (e.g. sleeping o:1 guard, losing equipment,et0.), or receiving a negative Special Observation Report for a more serious rulesviolation (e.g. eating unauthorized food). We reclassified a few cases of academicwithdrawals as medical attrition when there was an underlying medical condition whichcaused the soldier to fail a critical patrol (e.g. patrol leader shot in the eye with a blankround during assault on an objective, or a soldier evacuated from the field for highfever related to cellulitis infection, before he could be graded for another patrol).

PHYSICAL TESTS

Body compositlon

Body weight, body composition, and anthropometric measurements were madeat baseline and at the end of each training phase. Time constraints did not permit allmeasurements to be made at each of the five data collection times (summarized inTable 3).

Unless specifically noted, all measurements pertaining to body compositiunwere made before subjects were permitted to eat on the data collection days. Nudeweights were obtained using an electronic scale (SECA Model 708, SECA InstrumentCo., Columbia, MD). A single set of linear anthropometric measurements wascollected prior to beginning the study which included standing height (in stocking feet),sitting height, firm crotch height, and arm span (measured against a corner wall).

Six circumference measurements were made using a flexible steel tape overbare skin by an experienced anthropologist and a spotter (26). The six circumferencemeasurements made were: flexed bicep, neck, shoulder, abdomen at the navel, hips,and thigh. Skinfolds were measured at four sites (biceps, triceps, suprailiac, andsubscapula) as described by Durnin and Womersley (27). Skinfolds were measuredthree times and the measurements averaged.

Bone mass and soft tissue composition were measured using dual energy x-rayabsorptiometry (DPX-Plus, Lunar Corp., Madison, WI), using methods described byMazess et al. (28). Absorptiornetry measurements were made at the beginning of the

18

study and at the end of Phases III and IV. Subjects were measured using a 10-minute "fast scan" mode, and measurements made on each subject at the ends ofPhases III and IV were made on the same instrument the subject was originallymeasured on at the initiation of the study. Precision of the measurements for percent

body fat is better than +0.5% body fat units and for bone mineral content, +0.040 kg

(29).

HandgriD strength

Maximal isometric handgrip force was measured at the beginning of the studyand at the end of phase IV using a customized ergometer which included a BLHelectronic load cell transducer connected to a data acquisition system (30). The grip-

dominant hand was tested in 3-4 trials, alternating between test subjects to encouragecompetition and permit muscular recovery between replicate trials. The grip devicewas adjusted to fit each individual before each trial.

Volunteers were instructed to keep their elbow in contact with the table and to

position their shoulder over the elbow, keeping the elbow joint at approximately 900.If the elbow was lifted from the table the trial was not used. Because the grip devicewas not anchored to the table, the test only measured the force provided by thefingers and thumb of the hand attempting to come together. Force was plotted in real

time on a screen display in front of the subjects and subjects were verballyencouraged to produce their best effort. Peak force values were recorded and the

highest two values from three trials were averaged. Only values which were within10% of each other were used, and an additional trial was conducted in order to verify

the highest value, in cases where adequate agreement between measurements wasnot achieved in three trials.

Handarlp endurance

Handgrip force endurance was measured by determining the holding time at

60+2.5% of maximal handgrip force (31). A screen display of the target force gavesubjects two horizontal lines at 57.5% and 62.5% of maximal handgrip force andproduced a real-time plot of a subjects holding performance. The volunteers wereinstructed to maintain a force within these limits, and when their grip force fell below

57.5% of the maximum for over 2 seconds, the test was terminated and the time in

seconds recorded.

19

Five handgrip endurance measurements were made for each soldier (initial andat end of each training phase) using 60% of the maximum handgrip strength achievedat the baseline measurement period. A single handgrip endurance measurement wasmade using the maximum handgrip measurement taken at the end of Phase IV.

Maximal dynamic lift

Maximal lift capacity was measured before the course began, and at the end ofPhases III and IV using instrumentation and methods described previously (31). Forthis procedure, weights are added to a carriage, to which handles are attached, andthe carriage slides upward on a vertical track. The subject began by lifting 18 kg,followed by the addition of weight in each subsequent trial in increments of 18 kg untildifficulty was encountered. Additional weight was added in increments of 9 kg until amaximum lift ability was achieved. A successful lift was defined as one in which thesubject was able to raise the weighted carriage to shoulder height in one clean motion.

MEASUREMENT OF ENERGY EXPENDITURE & WATER TURNOVER

The experimental design for the energy balance and water turnover portion of thestudy is shown in Table 4. A limited supply of H2'0 resulted in energy expendituremeasurements using the doubly labeled water (DLW) method being made on only 43days of the 63-day experiment, and the number of DLW subjects was limited to six perphase. After attrition, the final number of DLW subjects for phases I through IV was5,5,6,5, respectively. The mean age (23 yr), height (178 cm) and physicalcharacteristics of the DLW subjects were similar to the overall group characteristics.Changes in baseline isotopic enrichment was simultaneously monitored in cohortgroups of Ranger students who did not receive 2H, 80. During the three periodsbetween DLW measurements, total daily energy expenditure (TDEE) was estimated as[(total intake balance energy expenditure - total DLW energy expenditure)/20 days).

The DLW (2H2'0) method of measuring TDEE (32) is based on the assumptionthat after an initial oral dose of stable 2H2

180, deuterium (2H) is eliminated from thebody as water, whereas 'S0 leaves as both water and exhaled carbon dioxide (CO2).The rate of CO2 production (Vco2) can be calculated from the difference in eliminationrates of the two isotopes. Energy expenditure is calculated from Vco2 using ametabolic fuel quotient and conventional indirect calorimetric relationships. Total body

20

Table 4. Experimental design for energy balence and water turnover studies.

Phase RAP & Benning Mountain Jungle Desert

Day of course 2 3 6 10 19 20 22 26 32 36 39 49 S6 57 3

DLW dose / ,

Saliva sample V / / /

Urine sample v/ rr' I ,/" /f / // w

water, isotopic elimination rates, carbon dioxide production, and metabolic fuelrespiratory quotient were calculated using standard methods (33) as previouslydescribed (34,35) This method has been validated in soldiers in the field (34,35).

Water influx and efflux were measured by administering the stable, non-radioactiveisotope 2H 20 and following the decline over time in the isotopic enrichment of bodywater (36,37). The isotopic enrichment of body water declines due to the eliminationof labeled water via excretion and evaporation, and the influx of unlabeled water fromdietary, metabolic, and atmospheric sources. The 2H20 elimination method ofmeasuring preformed dietary water intake has been validated in humans (38), and thetritiated water elimination method has been validated in animals (37). We estimatedapparent total water turnover from deuterium distribution space and elimination rates.About 10% of the apparent total water turnover can be attributed to metabolic waterproduction and respiratory and cutaneous water influx.

Intake balance energy expenditure was estimated using standard methods (39).Food intake was estimated from the overall ration schedule for the course (Table 2).A total of 56 of the 107 meals (52% of the meals; 41% of the total kcal consumed)consisted ot one Meal-Ready-to-Eat ration (1300 kcal/meal). A total of 41 of the 107meals were A rations. Energy intake for A ration meals was estimated at 2246 kcal(two times the calculated energy content of a standard serving). Of the remainingmeals, 7 were B rations (estimated calorie content a 1433 kcal/meal) and three werebox lunches (estimated calorie content = 690 kcal/meal). The change in body energystores (,ES) was estimated using the body composition measurements obtained byDEXA, using the equation: (AES) a (fat mass x 9.5 kcal/g) + (FFM x 0.27 x 4.4kcal/g), where FFM is fat free mass corrected to dry weight, assuming 73% water.

21

BIOCHEMICAL MEASUREMENTS

Blood samples were collected from each soldier prior to beginning the course,and at the completion of each of the four training phases. The fasting blood sampleswere collected into vacutainer tubes; all blood collections were conducted between0430-0900 h from soldiers in the seated position. Following collection, blood sampleswere kept cool (approximately 15*C) until processing (completed within 4-5 hours).Serum (or plasma) and cells were separated, and the different blood fractions frozen(-20°C) until shipment on dry ice to the analytical laboratory. In all cases sampleswere frozen when received by the laboratory. Five blood samples (total volume of 35ml) were taken from each soldier at each collection point to provide samples forbiochemical analysis and immunological testing.

Clinical Chemistries

Blood samples were analyzed for general indicators of health and nutritionalstatus. The following tests were performed on serum using a Beckman Synchron CX5automated chemistry analyzer (Beckman Instruments, Fullerton, CA) withmanufacturer recommended reagents.

Test Method WavelenathGlucose hexokinase/G6PDH 340 nmBlood urea nitrogen urease/glutamate dehydrogenase 340 nmSodium ion selective electrodePotassium ion selective electrodeChloride ion selective electrodeUric acid uricase/peroxidase 520 nmTotal protein biuret 560 nmAlbumin bromcresol purple 600 nmCalcium arsenazo III 650 nmPhosphorus molybdate 520 nmMagnesium calmagite 520 nmCholesterol chol est/chol ox/peroxidase 520 nmTriglycerides lipase/glycerol kinase/G1 PDH 520 nmTotal bilirubin modified Jendrassik-Groff 560 nmLactate dehydrogenase lactate to pyruvate 340 nmGamma glutamyl transferase gamma glutamyl p-nitroaniline 410 nmIron ferrozine 560 nmTotal iron binding

capacity (TIBC) MgCO3/ferrozine 560 nm

22

Percent iron saturation was calculated using the equation: serum ironconcentration/TIBC x 100. Serum f3-hydroxybutyrate concentration was determinedusing the Beckman Synchron CX5 using 0-hydroxybutyrate dehydrogenase method(Diagnostic Kit 310A, Sigma Chemical Co., St. Louis, MO). Ferritin was determined induplicate aliquots of serum using an IRMA kit (BioRad Laboratories, Richmond, CA)with standards prepared against the First International Standard.

The following assays were conducted on plasma samples with EDTA as theanticoagulant using the Beckman Synchron CX5 automated chemistry analyzer withmanufacturer recommended assay systems, unless otherwise noted.

Test Method WavelengthGlycerol glycerokinase/pyruvate kinase/LDH (Sigma)Lactate lactate dehydrogenase (Sigma)NEFA acyl CoA synthase/oxidase/peroxidase (Wako) 560 nmAST aspartic acid/ci-keto glutaric acid/

malate dehydrogenase 340 nmALT alanine/ci-keto glutaric acid/LDH 340 nm

HDL-cholesterol was determined on EDTA-treated plasma using dextran sulfate(MW 50,030) precipitation with DMA (eagent and analyzed for cholesterol on theBeckman Synchron CX5 analyzer using a cholesterol oxidase method.

Routine chemistrias were verified daily by performing quality control proceduresusing BioRad unassayed chemistry controls and monthly comparisons were made inan interlaboratory quality assurance program. Standardization was also confirmedthrough participation in the College of American Pathologists Survey.

Nutritional Assessment

Selected vitamins and iron status were assessed using their respectivebiochemical markers as listed in Table 5, using the methods described below.

Vitamin A (retinol) was determined by HPLC using heparin plasma samplesextracted into hexane after addition of B-apo8'-carotenal (internal standard) andseparated with 100% methanol through an ODS Hypersil 3 pm column, with UVdetection at 320 and 450 nm; recovery averaged 98%.

23

Table 5. Measured Blood-borne Biochemical Markers of Vitamin and Iron Status

Nutrient Sample Biochemical marker Lower limits of normal

Vitamin A heparin retinol concentration > 1.05 gmolA.(retinol)

Thiamin 118C in vitro stimulation of erythrocyte < 15% stimulation(Vitamin Bj) transketolase activity by thiamin

pyrophosphate

Riboflavin RBC in vitro stimulation of erythrocyte < 40% stimulation(Vitamin B.) glutathione reductase activity by

flavin adenine dinucleotide

Vitamin B6 RBC in vitro stimulation of erythrocyte c 100% stimulation(pyridoxal) glutamate oxaloacetate transaminase

activity by pyridoxal-5'-phosphate

Vitamin BU2 serum Vitamin BU concentration > 148 pmoVL(cyanocobalamin)

Vitamin C heparin ascorbic acid concentration > 30 !gmoVL(ascorbic acid)

Vitamin D serum 25-hydroxycholecalciferol concentration > 32 nmol/L

Folacin RBC erythrocyte folacin concentration > 360 nmoVLserum folacin concentration > 5 nmoVL

Iron serum total iron concentration, > 10 iLmoVLtotal iron binding capacity (TIBC), > 40 pmoVLferritin > 10 pg/L

Abbreviations for blood fraction & anticoagulant: heparin - heparinized plasma, serum= untreated serum, RBC - washed red blood cells from blood collected in EDTA.

Vitamin B2, and folic acid were measured in EDTA plasma using a combinedradioreceptor assay (BioRad). The procedure used a boiling step to eliminateinterferences by endogenous binding proteins and "'Co and '261 were counted followingcompetition for binding with intrinsic factor (Vitamin 82) or binding proteins (folate).The same method was used for determination of RBC folate on samples treated withascorbic acid at the time of collection.

24

Red cell levels of three enzyme markers of B vitamin status (Table 5) and

stimulation of their activity with the addition of exogenous vitamins were based on

methods developed by Bayoumi (40) and Vuilleumier (41) and adapted to theBeckman Synchron CX5. Percent stimulation was determined as:

100 x (activity with vitamin - activity without vitamin)/activity without vitamin.

These assays were performed on a hemolysate collected and preserved as follows.

Red cells collected from EDTA treated blood were washed twice with normal saline

and frozen until analysis. Samples were thawed and hemolyzed by adding 2 mIs of

cold deionized water per 500 IL of red cells. Hemoglobin was determined on thehemolysate and samples were then diluted with deionized water to achieve a final

hemoglobin concentratior, o' approximately 1 g/dL. Activity was expressed in IU/g

hemoglobin.

Red cell transketolase and stimulation with thiamine pyrophosphate (TPP) were

determined by performing 2 runs per sample, one on a reagent system containing

TPP and the other not. The reagent system was composed of ribose-5-

phosphase/xylulose-5-phosphate/tnose isomerase/glycerol dehydrogenase.

Red cell glutathione reductase and stimulation with FAD were determined by

performing two runs per sample, one on a reagent system containing FAD and the

other not. The reagent system consisted of oxidized glutathione/NADPH and buffer.

Red cell AST and stimulation with pyridoxal phosphate were performed using 2

runs with the Beckman AST reagent cartridge, one with and the other withoutincubation of the sample with pyridoxal phosphate.

Vitamin C in hepannized plasma was determined on the Beckman Synchron

CX5 using a method developed in-house (at Pennington Biomedical Research Center).

Upon thawing, samples were treated with 50 gL of metaphosphonc acid/dithiothreitol

per 500 jiL of sample to stabilize the ascorbic acid. The method uses ascorbateoxidase to convert ascorbic acid to dehydroascorbic acid (DHAA), which then reactswith o-phenylenediamine (OPDA) to produce an adduct which absorbs at 340 nm.Interferences and endogenous DHAA were removed by reacting for 5 minutes at 37Cwith OPDA. The reaction is then catalyzed by the addition of ascorbate oxidase andthe rate of reaction followed for 5 additional minutes. The method is linear to at least

25

200 mg/L and recovers 94% of added ascorbic acid.

25-hydroxy-vitamin D was determined in duplicate in serum using an RIA kit(Incstar Corporation) with acatonitrile extraction. Specificity of the antibody was equalfor the D2 and D3 forms; crossreactlvity for 1,25 dihydroxy compounds and cholesterolwere 5% and 1%, respectively.

Normal reference values were based upon ranges established in military andcivilian nutritional assessment studies as specified by Sauberlich (42), unlesssuperceded because newer methods of analysis were used (43) or because normalreference values for the laboratory at which the assays were performed (PenningtonBiochemical Research Center) were different. Reference values for the vitaminsmeasured in this study are given in Table 5.

Endocrine rnarkets of nutritional status

Hormona assays were performed using commercially available kit procedures.All samples for an individual were processed in duplicate in the same assay batchjsing aliquots of serum which had been stored at -45°C for up to 6 months.Testosterone, estradiol-1 7p, cortisol, aldosterone, and insulin were measured byradioimmunoassay (Diagnostic Products Corp.), with interassay coefficients ofvariation (CV) of 7.7%, 5.4%, and 8.5% for the first 3 hormones, respectively. Insulinand aldosterone were measured only in a single assay subsample of 16 soldiers.Because of its extreme sensitivity to repeated freeze-thaw cycles, insulin wasmeasured after a single thaw. Insulin was calibrated against 1st IRP 66/304;sensitivity was 2 pIU/ml. Sex hormone binding globulin was measured by IRMA(Farmos Group Ltd, Finland) with mouse monoclonal antibody, with interassay CV of6.3%. Serum insulin-like growth factor-I (IGF-l) was measured in single thaw aliquotsby RIA after acid ethanol extraction (Allegro, Nichols Laboratories), calibrated againstWHO 1st IRP 87/518, with 14.3% interassay CV. Growth hormone was measured byan avidin coated-bead RIA with 2 mouse monoclonal antibodies (Allegro, NicholsLaboratories), calibrated against NIAMDD-hGH-RP-1, sensitivity to 0.02 ng/ml, andintgrassay CV of 10%. Luteinizing hormone (LH) was measured by IRMA (ICNBiomedicals, Inc), calibrated against WHO 1st IRP 68/40, with 7.0% interassay CV.Data on serum triiodothyronine, thyroxine, thyroid binding globulin, and thyroidstimulating hormone was still being compiled at the time of this report and will appearelsewhere. For this study, acceptable intraassay CVs for all assays were < 5%.

26

MICROBIOLOGICAL & IMMUNOLOGICAL PROCEDURES

Hematologv

At each measurement period, complete blood counts (CBC) and white bloodcell differential counts were obtained on a blood sample drawn into EDTA-containingvacutainers. Automated differential counts and CBCs were determined on samplesfrom the baseline, phase I, and phase II measurement periods using a Technicon H-6000 analyzer (Technicon, Inc., Tarrytown, NY) at Martin Army Community Hospital,Ft. Benning, Georgia. Blood counting on samples collected at the end of phases III(USAF Regional Hospital, Eglin AFB, FL) and IV (William Beaumont Army MedicalCenter, Ft. Bliss, TX) were done using a Coulter Model STKR analyzer (CoulterElectronics, Inc., Hialeah, FL). Differential counts were not obtained on blood samplescollected at the end of phase I.

Cell-mediated Immune function

At each collection point, a blood sample was collected into siliconizedvacutainer tubes containing sodium heparin (143 USP units) for immune studies. Theblood was held at ambient temperature (18-2rC) for 24 h prior to preparation for invitro cell culture. This timing was designed to equate the handling of samples fromeach phase by accommodating the longest period of travel between test sites and theimmunology laboratory in Beltsville, Maryland. Plasma for cytokine quantitation wasremoved from packed cells at approximately 32 h post-collection. The plasma

samples were held at -70°C until analysis.

Whole blood was diluted 1:4 and 1:2 with RPMI-1 640 tissue culture medium(Sigma Chemical Co., St Louis, MO) in polystyrene tubes for lymphocyte proliferationand cytokine production cultures, respectively. The RPMI-1640 contained L-glutamine

at 2.0 mmol/L and penicillin-streptomycin at 100 U/mL and 100 Ag/mL, respectively.The in vitro cultures for proliferative responsiveness received in order: 100 IL ofRPMI-1640 per well of round bottom 96-well tissue culture plates, 50 PL of RPMI-1640alone (background) or with designated stimulant: phytohemagglutinin-M (PHA-M; 0.08ug/p.L, Sigma), conconavalin-A (ConA; 0.08 pg/pL, Sigma), pokeweed mitogen (PWM;0.008 Vg/pL, Sigma), or tetanus toxoid (IT; 0.128 Lf/pL, Connaught LaboratoriesInternational, Willowdale, Ontario, Canada), and 50 MiL of blood (diluted 1:4). Thecultures contained a final volume of 200 pL, with the final blood dilution at 1:16.

27

Proliferative activity in vitro was based on mean DNA incorporation of tritiatedthymidine (methyl-3 H; specific activity 6.7 Ci, 248 GBeq/mmol, New England Nuclear,Boston, MA) by cells in triplicate cultures without (background) and with stimulant.PHA-M and ConA were added to the cultures at 4 lag, and PWM at 0.4 lag, perculture. TiT was added to the cultures at 6.4 limits of flocculation (Lf) per culture. Cellcultures stimulated with PHA, M and ConA were incubated for 72 h, and thos9stimulated with PWM and TT for 144 h, at 37°C in a 5% C0 2, 95% humidified airincubator. 3H-thymidine (1.0 uCi; 37 KBeq) was added to each culture 24 h prior totermination, after which cells were harvested, the 3H-thymidine labeled DNA wascollected cn 12-well filtermats (Skatron Inc., Sterling, VA), 4.5 mL of scintillation fluid(Ready-Safe, Be nan) was added to each vial containing individual filter discs, andthe vials were coL ied (Beckmavi LS 3801 scintillation counter). Proliferation activityof lymphocytes is expressed as corrected dpm (stimulated minus background).

For cytokine productioi the cultures received the same treatment as theproliferative activity cultures, wc:h PHA-M, CunA, or PWM stimulants, but with 50 4L ofblood diluted 1:2 instead of 1:4.. The cultures also contained a final volume of 200gL, but with the final blooddilution at 1:8. The cell V Blastogeneslscultures were incubated Blood 12.5 uL/well* 25 uL/wellsimilarly to those forlymphocyte proliferation, RPMI-1640 187.5 uL/well 175 uL/wellexcept for 48 instead of 72 h

for PHA-M and ConA- PWM 0.4 ug/well 0.4 ug/wellstimulated cultures, and 96 Time 6 d 4 dinstead of 144 h for PWM-

stimulated cultures. The PHA&ConA 4.0 ug/well 4.0 ug/wellsupernatants from each set of Time 3 d 2 dtriplicate cultures werecollected, pooled, and stored Tetanus 6.4 Lf/well 6.4 Lf/wellat -700 C until assayed. A Time 6 d 4 dsummary of the blastogenesisand interleukin assays Assay 3H-TdR ELISAconditions is given in Table 6.

*Round bottom plateCytokine interleukin-2 Table 6. Cell culture conditions for immune function

(IL-2) was determined in studies.

28

supernatants from unstimulated and PHA-I,-stimulated cultures by a commerciallyavailable ELISA (Dupont Boston, MA). Cytokine interleukin-6 (IL-6) was determinedin supernatants from unstimulated cultures and plasmd by ELISA test kits (Clinigen,R&D Systems, Minneapolis, MN). Soluble IL-2 receptors (IL-2R) were determined insupernatants from PHA-M stimulated cultures using the CELL-FREE Interleukin-2Receptor Test Kit (T-Cell Sciences, Inc., Cambridge, MA).

Delayed .skin hypersensitivity test

Changes in the ability of soldiers to express an in vivo immune response wasassessed by administering a delayed skin hypersernsitivity test (Multitest-CMI,Connaught Laboratories, Inc., Swiftwater, PA) to each soldier during the base'inemeasurement period, and at the end of trai,,,"g phases III and IV. It contained aglycerin nqgative control and seven antigens oi culture filtrate from the followingmicroorganismrn: Clostridium tetani (tetanus toxoid), Corynebacterium diohtheriae(diphtheria toxoid), Streptococcus, Group C (streptococcus), Mycobacteriumtuberculosis (tuberculin, old), Candida albicans (candida), Trchophytonmeriaqrophytes (trichophyton), and Proteus mirabilis (oroteus).

The tine tests were applied to the ventral forearm of each soldier in themorning, but after blood samples had baen taken. After forty-eight hours, theresponse to each antigen was determii.ed by measuring the diameters (parallel andperpendicular to the long axis of the forearm) of the induration resulting at each of theeight tine administration sites. Tho site was recorded as a positive reaction when itshowed an induration of 2 mm in diameter or more, compared to the negative control.

NasoDharyngeal and nasal microbloloqic&l cultjres

Nasopharyngeal (throat) and nasal swab specimens were obtained from each

soldier at each measurement period in order to monitor relative changes in theprevalence of carriers of Group A 3-hemolytic Streptococcus (throat) and S.pneumor~iae (nasal). Nasal and nasopharyngeal swabs were obtained from eachsoldier at the beginning of the course (prior to penicillin G prophylaxis; Bicillin LA,Wyeth Laboratories, Philadelphia, PA) and at the end of each of the four trainingphases. Throat swabs were collected from each soldier using rayon tip swabs(Precision Bioport 6, Precision Dynamics Corporation, San Fernando, CA) withModified Stuart's medium and cultured to determine the presence of Group A •-

29

hemolytic Streptococci. Nasal swabs were collected using calcium alginate swabs(Calgiswab Type 1, Spectrum Laboratories, Inc., Houston, TX) with Modified Stuart'smedium, and cultured to identify the presence of S. pneumoniae.

The bacteriology was performed by clinical laboratories at the nearest military

medical treatment facility in each phase (Martin Army Community Hospital, FortBenning, GA; USAF Regional Hospital, Eglin Air Force Base, FL; William BeaumontArmy Medical Center, Fort Bliss, TX). Each swab was inoculated onto separate petridishes containing Trypticase Soy agar with 5% sheep blood (BAP)(Becton DickinsonMicrobiological Systems, Cockeysville, MD) or Strep A Isolation agar (Remel, Lenexa,KS). The BAP was used for isolation of S. pneumoniae while the Strep A Isolation

agar enhanced the recovery and identification of P-hemolytic Streptococci. The plateswere incubated 18-24 hours at 35 °C in an atmosphere of 5% CO 2. Isolates wereidentified usiog standard bacteriological methods (44,45).

PHYSICAL EXAMINATION

A physician conducted a visual examination of each soldier (in the nude) at the

completion of the study in order to ascertain the presence of any outward clinical signs

of malnutrition or nutrient deficiencies. The examir'.ation emphasized jaundice,cheilosis, glossitis, edema, and history taking. Such general clinical assessment hasbeen reported to be reproducible and valid in comparison to laboratory measurementssuch as delayed cutaneous hypersensitivity, changes in blood albumin and transferrinleiels, and body composition (46). This exam was repeated foi a few of thevwluntet.rs six months after the end of the course, as reported i-, ppendix IV.

STATISTICAL ANALYSIS

Of the original 190 Ranger trainees which comprised the sample for baselinemeasurements, 55 remained to provide final measurements. For most measurements,

only data frcm these trainees are reported. However, some data collected fromsoldiers who left the clasx at earlier stages are reported when the data provides useful

comparisons; these instances are specifically noted in the text. The data wereanalyzed using a one-way repeated measures analysis of variance, and means withinthe test population were compared across time using paired t-tests using SPSS-X(47). A Scheffe's multiple range test was used in some instances to make more

comprehensive comparisons between sampling intervals; differences are indicated by

dissimilar letters. Tabular data are reported as means+standard deviation.

30

RESULTS & DISCUSSION

MEDICAL ATrRITION

Of the 190 subjects who started in the study, 33 (17%) completed the Rangercourse without recycling a phase. Another 47 soldiers from our original study groupgraduated with the following class in November, and 10 graduated in December, foran overall success rate of 47% for our study group.

Grouped according to their pre-Ranger training origin, the soldiers sent byRanger units had a higher overall success rate, and Lieutenants sent from OfficerBasic Courses had a lower overall success rate, compared to the average (Table 7).

Table 7. Success rate by pre-Ranger training origin.

Officer basic courses 7 20 35.0%

Fort Bennlng GULAG (recycles) 17 39 43.6%

Other units 46 97 47.4%

Ranger units 20 34 58.8%

Total 90 190 147.4%

Academic failures accounted for the majority of drops and recycles from theclass (69%), with medical problems accounting for 25% of this group (Table 8). Theseresults are shown by phase in Figure 2. Medical withdrawals from the class resultedmost often from orthopedic injuries (including 2 fractures and 3 stress fractures) andheat injuries. Infections accounted for less than 13% of all medical withdrawals. Atleast 13 of the 39 medical withdrawals were recycled into the next class, including 4out of the 5 cellulitis infections and 7 traumatic injuries; eleven of these medicallyrecycled soldiers graduated In one of the next 2 classes. Nearly all heat Injuries andwithdrawals for blisters and other foot problems occurred during the RAP. Many ofthe orthopedic Injudes, including both fractures and 1 of the 3 stress fracturesdocumented In this class, occurred during mountain training. Withdrawals for cellulitisoccurred primarily during the jungle phase (Table 8).

31

Table 8. Reasons for class attrition (drops and recycles) at each phase ofRanger training.1 Of this group, 36% successfully recycled and graduatedwith one of the next 2 classes, bringing the course success rate to 47%.

Categor'A fRP 1. 'l1' j IVj TOWMedical (total) 21 2 7 7 2 39

---heat injury 9 1 (10)

---orthopedic injuries 4 6 3 1 (14)

---cellulitis 1 4 (5)

---eye iniury 2 1 (3)

---72 h profile 1 1 (2)

Academic/RAP testing2 44 8 22 6 21 101

Peer evaluation 1 1 2 4

Special Obs Report (SOR) 2 2 4

Lack of motivation (LOM) 1 1 1 1 4

Administrative 2 1 1 1 5-I I____ --

Total attrlted I 68 1 3 =41:1: 5 1

Total starting phase 190 122 109 75 58 33,__{grads

Total available for study' ( ". I 10 93 68 55] -1

'RAP-Ranger Assessment Phase, I-Benning, I1.mountains, Ill-jungle, IV-desert.

2During the RAP, academic withdrawals included failures on the Army Physical FitnessTest (6). Combat Water Survival Test (3), 5-mile run test (4), 8-mile footmarch test (13), day/nightland navigation (15), and military skills test (3).

'This includes some of the soldiers who were recycled for the phase, i.e. this may includemore soldiers than the number starting the next phase. Thus, 55 soldiers of 58 soldiers whoadvanced to the desert phase were studied at tMe end of the phase (2 SORs and 1 medical recyclehad already been separated from the group); however, only 33 graduated and the other 22 studiedwere recycled in the desert phase.

"No data were collected at the end of the 4-day RAP phase, other than reasons for attrition.

32

Peret of a soldiers studied (nM190)

25

20. . . . . . . ..

i s . ....................................................................... I... .................. ...

10 ......

0RAP I II III IV

Percent of solers in ph.senel.O nu122 na.100 n,-75 [rom

s0o..... . .......

m40 ...

20.....

RAP III IIIIV

Figure 2. Percent of soldiers attrited or recycled for academic and medical reasons,expressed as percent of all soldiers studied (upper graph) and as percent of soldiersstill present in each respective phase (lower graph).

33

The reasons for attrition from the course, the volunteers who ultimately left thecourse without successfully completing the requirements for the Ranger tab, aresummarized in Table 9. This represents a subset of the group summarized in Table8, with the recycled study volunteers who were eventually successful subtracted out.After the 4-day RAP, cellulitis in the jungle phase and orthopedic injuries in themountain phase were the predominant medical causes of attrition.

Certain medical problems, usually common within a specific training phase,primarily received self-treatment and tended to escape treatment documentation bythe medics. These problems included chigger bites and poison ivy dermatitis duringphase I, severe abrasions on the bony processes of the back caused by thecombination of friction, moisture (rain), and pressure from the rucksack ("ruck rash")during the mountain phase, and complaints of back strain towards the end of thejungle training phase. Foot problems were common to all phases of the training.

Table 9. Reasons for course attrition, a. it, Table 8, except without thoserecycled soldiers who graduated in the next 2 classes.

Medical (total) 18 2 5 3. 0 28

---heat injury 9 1 .(10)

---feet/blisters 4 (4)

---orthopedic injuries 4 5 1 0 (10)

---cellulitis 0 2 (2)

---eye injury 0 0 ....0(0)

---72 h profile 1 1 (2)

Academic/RAP testing 33 7 13 1 7 61

Peer evaluation 1 0 2

Special Obs Report (SOR) 1 2

Lack of motivation (LOM) 1 1 1 1 4

Administrative 2 0 1 0 1 3

Total attrited j 541 111] 221 5 8 110

34

INFECTION RATES

The end-of-phase review of medical records for the mountain, jungle and desertphases revealed that 13 (39%) of the soldiers who completed the course withoutrecycle had been treated with antibiotics for infection. The majority of these infections

involved cellulitis of the lower extremities, usually cellulitis (and/or bursitis) of one or

both knees. The prevalence of clinically significant infections markedly increased from

8% (9/109 soldiers) in the mountain phase, to 25% (19/75) and 24% (14/58), In jungleand desert phases, respectively (X2 test; p<0.01)(Table 10).

The prevalence of Group A 0-hemolytic Streotococcus carriers in this study waslow (Figure 3). Before the penicillin prophylaxis, the prevalence was 3% (6/186) andthis varied from 2% (2/117), at the end of the first phase, to 5% (3/56) at the end ofthe course. There were no reported cases of Streptococcal pharyngitis in the course.

Table 10. Infections documented in medical records which were treatedwith antibiotics during the last 3 phases of training.

-------------- - - -- - -1 --- - -

Cellulitis

--knees 3 8 6

--leg 1 _

--ankle/feet 3 2 2

--hand 1 1--multiple or unspecified 2

Folliculitis - legs 3

Eye infection I

Respiratory/airways Infection 3 4

Other infection 2

TotaVnumber of soldiers In phase 9/109 19/75 14/58(8%) (25%) (24%)

35

The prevalence of S. pneumoniae camers was also low, but rose significantlyduring the course. The prevalence of S. irneumoniae was 1% before the penicillinprophylaxis (2/186), and at the end of the first phase (1/117), bu•t the infection rateIncreased significantly (X2 test, p<0.05) during the mountain, jungle, and desertphases, peaking at 11% (8/70) in the jungle training phase. There were no cases ofpneumococcal pneumonia reported during the course.

Prevalence (%)12

S. pneumoniae

Group A Streptococcus

BICILLIN BICILLIN

2 --- ~~ ...... .... ....... I ......... !

0 L III 111 IV OL 1 11 111 IV

Figure 3. The prevalence of positive cultures of Group A 13-hemolytic Streptococci andStreotococcus oneumoniae before (BL=baseline) and at the end of each phase ofRanger training.

BODY COMPOSITION

Body fat was the only physical measurement made in this study which had anyrelationship to success in the course (Figure 4). Soldiers who began the coursebetween 10 and 15% body fat were more likely to be successful than fatter and leanersoldiers; however, soldiers with body fat spanning the entire range of the samplestarting the Ranger course were successful. This only suggests that the averageyoung soldier who is physically fit and prepared for Ranger training tends to fall in the

36

Number of soldiers

252 phases: 32% 48% 32% 31%4 phases: 20% 32% 26% 19%

20 ........

15~~~~ ~~ ..... . .. ..................

1 0 .. ............ ........................ ........ ... ..................

0 2 4 6 8 10 12 14 16 18 a20 22 24 26 28

Percent body fat

Figure 4. Distribution of Ranger students by initial percent body fat. Percentage ofsoldiers complellng halft of the course (2 phases)(solid bars) and finishing (4phases)(open bars) are given for 5% body fat intervals.

range of 10-15% body fat. Fatter soldiers and those who are excessively lean may beless likely to be in peak fitness although body fat outside of the 10-15% range doesWo preclude success in the Ranger course. In fact, the fatter but fit soldiers In thisstudy appeared subjectively to be better off towards the end of the course. Body fat

was the only physical measurement which was different between the unit of origin for

soldiers in this study, with the lowest body fat measured in soldiers from Ranger units

(13.4+4.3% body fat), recently arrived from a three week physically intensive RangerIndoctrination Program and highest In soldiers recently arrived from their Officer BasicCourse (1 7.0+4.8% body fat).

The differsnt;.q between these two groups in their preparation for the Rangercourse and In their motivation to succeed, both of which appeared to be better In thesoldiers from Ranger units, almost certainly explains some of the differential successin the course. Sin.:e the officers were not following an intense training regimen, unlikethe Ranger unit soldiers, and were fatter as a group, some of'the apparent relationshipbetween fatness and success in the course may be only coincidental.

37

Body weight declined by 12.1+3.4 kg (range of weight loss: 6.5 to 20.6 kg)during the course (data shown as a distribution in pounds of weight lost in Figure 5).The upper limit of safely attainable weight loss recommended by clinicians foroverweight patients is 2 pounds per week (e.g. AR 600-9). In the Ranger course ofjust over 8 weeks duration, this would amount to approximately 16 pounds; this wasthe lower limit of weight loss for soldiers in this study. This weight loss represented15.6% of initial body weight and all but two of the 55 finishers lost more than 10% oftheir initial body weight (Figure 6). The body weights at each phase for trainees whofinished compared to those who did not finish is shown in Figure 7. There was nodifference between mean body weights of finishers and nonfinishers at any phase.

Percent body fat declined from 14.6+4.2% (range 6-26%) at the start of thecourse to 6.9+2.7% (range 4-14%) and 5.8+1.8% (range 4-12%) at the end of the 3rdand 4th phases, respectively (Table 11, Figure 8). The apparent lower body fat limitof 4% corresponded to a lower limit of approximately 3.5 kg of fat, as the massestimated either from the DEXA measurements or calculated from the percentagebody fat obtained from the ratio of the attenuation of the two energies (r-value)(28)and body weight. Ranked by initial mass of body fat, only the fattest soldiers (initialfat weight > 12.5 kg) had greater than 5 kg of fat at the end of the course; thesesoldiers had continued to lose the largest amounts of fat during phase IV (Figure 9).Most of the soldiers achieved an apparent minimal level of 3.5 kg of body fat. Thisappears to represent "essential" rather than "storage" fat, the minimal amount of fatnecessary for life which makes up structural components such as cell membranes andnerve sheaths and some protective structures such as the perirenal fat.

Skintold thicknesses at the four sites measured declined significantly frombeginning to end (Figure 10). The sum of four skinfolds was not different betw6*nfinishers and non-finishers at any phase (Figure 7). The skinfold thicknessmeasurement had reached a plateau by the end of phase III and corresponded to aminimum skinfold thickness (i.e. no available subcutaneous fat) in six soldiers who hadalready reached an apparent minimum of body fat at the end of phase Ill. Thisminimum totaled 17-18 mm or 2.7, 3.7, 4.2, and 5.6 mm for the biceps, triceps,subscapular, and suprailiac skinfold thicknesses, respectively. The Dumin-Womersleybody fat equation for young males yields a density of 1.085 for these lowest skinfoldvalues, or 6.1% body fat. The lowest value obtained by Durnin & Womersley from 92men aged 20-29 was 16 mm, corresponding to 5% body fat by hydrostatic weighing(27). The mean values and changes in skinfold thicknesses are shown in Table 12.

38

Number of soldiers (total - 55)12 m 2 Ibs/week is the highest rate

4--ý recomendd toweight loss patients10

6 .... ...

6 .................................... .

4

2

0 4 8 12 16 20 24 28 32 36 40 44 48

Weight lost during Ranger training (Ibs)

Figure 5. Distribution of soldiers by weight loss (in pounds) during the course.

Number of soldiers (total - 55)10

median - 15.6% loss10% of krt•M W1

4

204 .. . .. .. ......

0 .2 -4 4 -4 -10 .12 .14 -16 .18 .20 -22

Percent change in body weightFigure 6. Distribution of soldiers by weight loss (as percent of initial body weight)during the course.

39

Body w.Ih Iql)

6033 1 s .- M- -n W b-%"W

-44n~m7 0 -- ... .................................. . I ..........................

40 0 M -BL I II III IV

Sm of 4 vkknol (mm)60b U mo~dmes .Sd uik .* A.

4 0 -. -........... .......... ........... ............................ .. ............................

r-44

3 0o -- .. . ........... ............ .............................................

20

SL I II III IV

Figure 7. Body weight (a) and -,um of four skinfold thicknesses (b) of nonfinishers stillremaining in the Ranger course at the end of each training phase, compared to finishers.

40

Numv*o ol soWiw, (n.5S)10 PERCENT BODY FAT AK START OF TRAINING

aaverage - 14.6%

(5.7-26.1%)

4

2

PERCENT SODY FAT AT END OF THIRD PHASE14b 12 average - 6.9%

(4.3-13.9%):I~

2

PERCENT BODY FAT AT END OF TRAINING

25 average - 5.8%

C 2o (4.4. 119%)

10 |

0 2 4 6 8 10 12 11 16 19 20 22 24 26

Percent body fat

Figure 8. DistrIbution of finishers by percent body fat at the start of the Ranger course(a), at the end of the third phase (b), and at the end of the course (c).

41

Fat weaght (ft)

FaIIl k"In le 2 wM

10 . ............................................ . .

20

Individuals, ordered by initial fat wt

Change in fat4m.f tma (%)10

5 . ..... .. . ........... ..... ... ...... ,a ... .................................... ........

0

-1 0 ...... . . ......... ...... . ....... . ...... I........................ .......................... "..........

".is .... ............ ... . . ............ .. . ........ .I • k • " 1• F 11 t •I. .

-201

Individuals, ordered by initial fat wt

Figure 9. Fat weight of individuals ranked by initial fatness, showing tho fat lostin the first 3 phases and additional fat lost in the last phase of training (uppergraph) and relative changes in FFM for the same individuals (lower graph).

42

Skinfold thickness (mm)20 *Ia

1 5 1.. .... . ..

a

I a bbb

lot bb ... bcc

CCC c

0Biceps Triceps "'ubscapular Suprailiac

Figure 10. Skinfo!J thicknesses measured at the beginning and end of each phaseof training. Bar height represents group mean (n=55); significant differences aredesignated by letters (Schetfe's test).

Of se ven circumference measurements made, the neck and flexed bicepsmeasurements changed the least, while the abdominal measurement and dght thighmeasurement changed the most, both in absolute and relative terms (Figure 11). Thechanges in shoulder and chest were intermAdiate in magnitude. The impact of thesechanges in circumference measurements oi the estimate of body fat by the Armyequation are shown in Table 11.

Fat-free mass declined by 4.6 +2.6 kg (6.9+3.6% of initial values); only arelatively small portion oi this loss occurred in the last 2 week phase: -0.3+1.5 kg, withsome soldiers actually geining or regaining fat-free mass during this last phase. Someof the largest losses occurred in soldiers starting the course with the lowest body fatreserves (Figure 9). One outlior was remarkable fur a decline in FFM whichapproached 20% and he looked particularly emaciated at the end of the course.

Figure 12 summarizes the mean body composition vaues as measured throughthe course with body weight and by DEXA. There was no measureable decline in themean bone mineral content (Table 11) although 6 soldiers demonstrated a decline of140 to 180 g, ,alues which are well outside the error of the mo'thod.

43

_Change Iom Wf Iq OiNmaursswg (aiM)0.

-2-

bIcep""

-10-Bt. I IIIII I

Figure 11. Relative change in circumference measurements made at the end ofeach phase of training, compared to starting measurements.

Weight (kg)

9FT 10.k945 o 37k

20

BL IllIIi IV

Figure 12. Mean weights of key components of body composition at the beginningof training and at the end of phases Ill & IV. BMC =bone mineral content.

44

;o to to ~ 0 CV

CD CD + +1 A 1 +I Q +1 8QO co VO C'Y

oD (o .r Lei*00

-, OD U

I-Y

(5t 0 V)

* ~ CM CM*)

V~O C) !-01 0ýU

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Cd))

0 l 0a) ) C' 'c 2 ')C q

LI) O) ( 0 0 w 0

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00DID%

t U~%J(I~.O Q) er) o+1++++ +1i~ *+1,+1 + +1 +1 Qc

oCO) 1 1 1 1 '01 CV U' o P O) CYJ i*q 0CMCV) ~C) CD O - cm

000

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CD 4l m .9 4l CM

I- +1ii+11

0n 0 DCl "r

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ci 0 CEli**0 ) % +1+ 1 + > 77 1T s I e-

Lo a I- P* M t LY t 0 N CV -D

~ ~CM CnCJ )L

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0)

N 0# )co L

N(C J -CJ- W) t 0G li=V

CV- V- C

C)L

E LoC o ,ca~~~~ CD,'JN~)O

,NCO1 ~ +- 0

V.--

a F _- _0

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32 a c .CC- 0C

0,U Lo 0 E cz

m___ J

STRENGTH MEASUREMENTS

Maximal lift capacity was markedly reduced at the end of the third and fourthphases but there was no significant decline in grip strength or grip endurance (Table13). Maximal lift capacity declined by an average of 40 pounds, from a median valueof 170 pounds to 140 pounds at the end of phase III, and 130 pounds at the end ofphase IV (Figure 13). This lower value achieved at the end of the Ranger course isthe average weight lifted by new Army recruits (based on a sample size ofapproximately 2,000 young males).

Maximal lift capacity correlated significantly with fat-free mass at the beginning(r=0.64) and at the end of the course (r,0.49). The change in fat-free mass was alsohighly correlated with the change in lift performance (r=0.49)(Figure 14). While themean values for maximal grip strength did not change during the course, there werealso significant correlations between fat-free mass and maximal grip strength pre(r.0.37) and post (r=0.40) and between the change in fat-free mass and change inmaximal grip strength (r-0.31)(Figure 14).

NUMBER OF SOLDIERS (n-49)164

'4 PON

12

10

8

681

4

2 -

0 LI1 14080 90 100 110 120 130 140 150 160 170 180 190 200 210

LIFT WEIGHT (Ibs)

Figure 13. Distribution of maximal lift performance at the beginning (solid bars)and at the end (shaded bars) of Ranger training. The median value of 130 poundslifted at the end of the course is the average fur ,.•w male Army recruits.

47

0 l) tr-

C 1O

CeCD

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0 L

CL

0.

dEEm LO L

E ~ ~ ~ c E E.a ~~

6 Lb e C

0

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S --- S. .--..m co

ai a

S0 o

asis

00m as_ __ 'S-S

(N tU~~l dSi xSV,'t4

*:~~~~l E ; . ~

Individuals losing the least and the most FFM were compared for strengthdecrements and yielded the same relationships obtained by simple correlations (Table14). There were no initial differences in physical characteristics of the soldiers atthese two extremes (e.g. height, weight, body mass index) except for percent bodycomposition measured by DEXA, with significantli higher FFM and lower percent bodyfat in the group which lost greater than 10% of their FFM during the course. Thisgroup demonstrated the greatest decrement in lift performance, with double thedecrement compared to the group losing the least amount of FFM. There was nodifference in the Initial lift capacity of these two groups (72.6+10.9 vs 74.6_+6.4 kg, forgreatest and least loss of FFM, respectively).

Table 14. Comparison of physical changes during Ranger training for soldiers wholost >10% FFM (n=9) and < 4% FFM (n=9); soldiers in the mid-range of FFM loss(n=37) are shown for added comparison.

Parameter (change) mid-range >10% FFM < 4% FFM t-test

Weight (kg) -12.1 +3.3 -14.2 +3.5 -9.7 +2.3 < 0.01

Sum of 4 skinfolds (mm) -22.5 +9.3 -19.3 +76.9 -21.4 +9.2 ns

Percent body fatoE0 -8.9 +3.0 -6.4 +2.8 -10.7 ±3.4 , 0.05

Percent body fa" -7.8 +2.1 -7.9 ±1.6 -7.5 +1.9 ns

Percent body fatA,,, -5.6 +2.5 -6.5 +2.0 -5.5 +2.7 ns

FFM (kg) -4.5 +1.1 -8.5 +2.6 -1.1 +',.1 0.08

Bone mineral (kg) -0.05 +0.08 -0.06 +0.07 -0.07 +0.11 ns

Fat weight (kg) -7.7 +3.3 -5.7 +2.7 -8.6 +3.2 0.07

Grip strength max (N) +1.6 +52.4 -23.2 +42.0 +13.6 +55.9 ns

Grip hold endurance (s) -0.9 +19.6 +1.7 +16.9 +3.0 +9.8 ns

Maximal lift (kg) -19.2 +7.2 -23.3 +12.4 -12.5+5.8 ,0.05

50

These data suggests that the maximal lift test is more affected by the loss ofmuscle mass than is the maximal grip strength. Handgrip strength probably has alarge muscle fiber recruitment involvement while maximal lift strength is largely afunction of the number of fibers (muscle cross-sectional area). Thus, caloric restrictionin Ranger training, as in other studies, apparently does not affect neuromotor controlbut clearly does reduce muscle cross-sectional area.

ENERGY EXPENDITURE AND WATER TURNOVER

The pattern of total daily energy expenditure (TDEE) is shown in Figure 15.The TDEE estimated by DLW and intake balance (4010.t830 kcat/day), and intakebalance alone (3930±290 kcal/day), were similar. The highest TDEE was during theclassroom portion of the Mountain phase when scheduled activities occupiedapproximately 19 hours/day; the second highest during the 4-day RAP period at thestart of the course. The TDEE estimates for the final FTX of the Ft. Benning phaseare less reliable than the initial measurements due to the high rate of water turnover

I-Ft. Benning-I- Mountains -I- Jungle -I- Desert -I

8000 8000

06000 -6000~

S4000 --- 40

DzLAJQ. 2000 20

00L5 0

LL 0 0 LA.

z0 0 I 2 20 0 4'0 ;0 60

TIME (days)

Figure 15. Total daily energy expenditure (solid line) and estimated food energyintake (dashed line) plotted over the course of Ranger training.

51

and the rupicd elimination of the DLW. The TDEE during the three periods betweenDLW measurements was calculated as 3140 kcai/day.

In Figure 15, estimated food energy intake Is plotted with TDEE. Energybalance, i.e., the net difference between food energy intake and energy expenditure, isshown in Figure 16. In the Ft. Benning phase, TDEE was the second highest of thefour phases but food intake was relatively high. As a result, the Ft. Benning phasecontributed the least of the four phases to the overall energy deficit (15%). Incontrast, the Mountain phase, with the highest TDEE and a low food intake,contributed the most (37%) to the overall energy deficit. The transition from theMountain to Jungle phases appeared to be a period of neutral energy balance. In theJungle phase, the combination of prolonged, moderate TDEE and low food Intakeresulted in a negative energy balance totalling 33% of the total energy deficit. TheDesert phase began with a period of refeeding and positive energy balance,moderating the overall energy deficit incurred after the food restriction and physicalactivity of the FTX (15% of total deficit). During structured periods of training in the Ft.Benning, Mountain, and Desert phases, 68% to 84% of the variation in TDEE couldapparently be ascribed to differences in the fat free mass (FFM) of the soldiers. On

I-Ft. Benning-I- Mountoins -I- Jungle -I- Desert -I

•-, 4000 15% 37% 33% 15%"0

U

-• 2000

0LLJC.)z 0o -- -im>- -2000

0L

zL J -4000

0 t0 20 30 40 50 6o

TIME (days)

Figure 16. Energy balance during the course of Ranger training. This representsthe next difference between food energy intake and energy expenditure.

52

average, TDEE was 4010kcai/day. with about 1230

r 0o kcal/day or 31% from bodyv.- energy stores, and 2780

6 a kcal/day or 69% from food71 consumed.

Estimated total waterW

turnover is shown in Figure 17.<• 4

3 ,These estimates of waterS 3 '2 ©LU U .turnover include not only!: 2 - , 0

2 % preformed drinking waterS- consumed, but also metabolic

0 2 3 4 water, water trapped in food,PHASE and water entering through the

skin and lungs. These latterFinure 17. Estimated total water turnover during the sources of water, which arefour phases of the Ranger training course. approximately 10% of total

water turnover or 0.5 to 1.0liter/day, can be subtracted from the total water turnover to estimate preformed dietarywater intake. Estimated preformed dietary water intake for each phase was: 7.4±1.2,(Ft. Benning), 5.3±0.6 (Mountain phase), 5.9±1.1 (Jungle phase), and 4.4±1.6 L/day,(Desert phase). These turnover rates demonstrate the emphasis by the cadre on highwater intake, especially in the first phase during the greatest heat strain.

CLINICAL CHEMISTRIES

Serum iron concentrations declined to marginally deficient levels at the end ofthe first 2 weeks of training but then climbed back to the normal range (> 9.0umol/L)(Table 15). Ferrltin, a key protein involved in iron stoldge, increased in theserum over the course of the study, possibly as a compensatory mechanism tomaintain normal iron levels.

Hemoglobin and hematocrit remained within normal limits throughout the coursefor all individuals as well as for group means (normal hemoglobin: ;14 g/dL; normalrange for hematocdit: 39-49%)(Figure 18). This was contrary to expectations because

53

of reports in the literature on "sports anemian in athletes working at high intensities forprolonged periods of time.

Liver function tests and enzymic markers of muscle metabolism all remainedwithin normal limits during the course (Table 16). Only serum levels of LDH (lactatedehydrogenase) demonstrated any meaningful rise and this remained within thenormal range (140-280 U/I).

Serum mineral and electrolyte concentrations remained unchanged throughoutthe course (Table 17). This indicated that there was no detectable electrolytedeficiency at the times where this would be most likely, when the soldiers had justcompleted the intensive field portion of the phase, on a schedule of one MRE/day.

Serum indices of energy and nitrogen metabolism may reflect the changes inmetabolism which occur in response to storage fat depletion, beginning midwaythrough the course (Table 18). Serum glycerol, nonesterified fatty acids, and I3"hydroxybutyrate increased at the end of the first and second phases and thendeclinbd, while urea nitrogen increased to the highest mean levels at the end of the

Hematology & iron status60 240

TIBC (ur,.N&) Fwritin (ug/L)

, o ..... ... .... .... ... .... .... ... ...... _.... ... .......... o50 - 200

Hct()4 0 1 . . . . • . ..... .. .. ... .... .. ... ........ ...... . .... ... .............. .. . . .. . 1W 0

Mb (g/L)

.. .. . ....... . .... .." . ... . . ... . ....... . . . . .. . ... .... .. .. ..

30- 120

Satrn Ns_

20 -

10. on -40

0 -0Si aIn IV

Figure 18. Iron balance and related hematological parameters during Rangertraining.

54

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to CC)Cl

C5 c V- V- ' '4.) 4.

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third p' ase. Although these are acute markers which would change rapidly with ameal or with exercise, these changes could reflect increased protein catabolism whenfat stores had been largely depleted, or they could simply mean that an adaptation tofat metabolism had occurred, bringing mobilization and oxidation into closer regulation.Nitrogen balance was not measured in this study but was presumably negative duringperiods of greatest energy deprivation; this is supported by the changes in endocrinenutritional markers such as IGF-1, described in the following section. There was nosignificant change In total protein or in serum albumin concentrations which alsosuggests the absence of chronic protein malnutrition.

Serum cholesterol demonstrated a progressive rise through Ranger training,with representative rises in both of the principal subfractions, but without any increasein triglyceride levels (Figure 19, Table 19). These serum lipid changes are consistentwith two other processes occuring during semistarvation: a diabetic-like state (withextremely low insulin levels and peripheral insulin resistance) and hypothyroidism(discussed further in a section below on endocrine changes). Both of these conditionsare well established underlying causes of hypercholesterolemia. Psychological stressproduces a marked suppression of the HDL-cholesterol subfraction, a response quitedifferent from these observations in Ranger students.

250

VLOL LDI. HDI.

200 .

150

100

8L I II I IV

Figure 19. Serum cholesterol subfraction levels at the beginning and end of eachphase of training (note the use of traditional mass units, mg/dL).

59

0

16 0; N C')

Cl)m

C;C62

MI9 q L (

cc ~w7

icc C -

C4 N

0 C4 N I

00

E j SO E -E9E Ch 0

VITAMIN STATUS

Serum vitamin concentrations increased over time in the course for severalvitamins, with a significant decrement in the middle of the course only for Vitamin A(Table 21). The absence of a change, or even a decline, in erythrocyte-stimulatedenzyme activities indicates that no deficiency evolved for thiamin, riboflavin, and B6.

Soldiers who used no vitamin supplements during the course had lower but stillnormal results (Figures 20 & 21), with statistically lower mean concentrations forserum B12 and 25-OH-D 3, serum and erythrocyte folate, and higher levels of enzymemarkers of B6 and riboflavin (Table 22). The decline in Vitamin A with an apparentrecovery even following the stressful third phase in the jungle environment cannot be

explained. The actual increase in some indicators of vitamin status suggests thatusing the nutrient fortified MRE (Table 20) and intervals of increased feeding, there isno critical nutrient deficiency. No differences in serum nutrient levels were foundbetween soldiers at the extremes of fat-free mass change, compared as in Table 14.

Table 20. Estimated average daily nutrient intake over the entire course & during

FTX days when soldiers received only a single MRE per day,.

MRDA' Average % FTX %

intake/day2 MRDA Intake/day MRDA

Energy, kcal 3200 2524 79 1306 41

Vitamin A, IU 5000 9905 198 4213 84

Vitamin C, mg 60 171 285 105 175

Thiamin (B,), mg 1.6 3.6 225 2.7 169

Riboflavin (B.), mg 1.9 1.8 95 1.1 58

Niacin, mg 21 21 100 13 62

Vitamin B., mg 2.2 1.8 81 1.9 86

Folacin, mcg 400 - 73 18

Calcium, mg 800-1200 1172 117 501 50

Iron, mg 10-18 13 93 6 43MRDA = Military Recommended Dietary Allowances for moderately active Army

pAersonnel (AR 40-25)(12).Average daily food intake predicted from data in the Ranger Operational Feeding Plan

and known nutrient composition of military foods.

61

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ENDOCRINE RESPONSES

Generalized stress markers changed significantly to indicate a progressivestress response through the course (Table 23). Testosterone, the principal male sexsteroid hormone is also one of the most sensitive and reliable stress hormone markersand this approached castrate levels by midcourse (Figure 22). Sex hormone bindingprotein (SHBG) doubled at the end of the first phase and remained elevatedthroughout the course with mean leveis just above the upper limit of the normal malerange. This is an expected part of the stress response, equivalent to the changeswhich occur in the much shorter but more intense (no sleep and no food) NorwegianRanger training course (14,15). This increase may be most directly attributable to thedecline In insulin levels because insulin is a key inhibitor of SHBG secretion. Thefunctional consequence of this rise is that the small amount of testosterone whichremains in circulation is more likely to be protein bound, resulting in even lowercirculating "free" testosterone, thought to be the biologically active fraction for sometissues. The decline in testosterone is explained by the observed 50% reduction inthe pituitary hormone LH. LH is the primary trophic factor for testosterone productionby the testes and is, in turn, regulated by hypothalamic hormones indicating that this isa centrally mediated stress response rather than a primary hypogonadism.

Testosterone (nmol/mL). LH (IU/L) SHBG (nrnoLiL)20 60

Testosterone

15 . . 50

10 -. - 40

LH

5 -30

0 I - 206L I II III IV

Figure 22. Declining serum testosterone and LH levels are indicators of ageneralized stress response; increasing SHBG levels reflect the caloric deficit.

66

Adrenal steroids are better markers of short term stress and tend to return to

baseline levels in chronic stress. However, in this study with progressive semi-

starvation, cortisol was highest at the end of the course, signifying the normal

response to a severe nutritional stress in the role of a metabolic hormone responsible

for mobilizing protein stores for energy and increasing circulating free fatty acids(Table 23).

Serum insulin levels declined by 50% within the first phase and remained at

these low levels at each end of phase sampling. Insulin-like growth factor-i (IGF-1)

declined to an even greater extent (Figure 23). This is one of the single best markers

of nitrogen or protein balance, with this fall indicating the severity of the energy

deficient diet and the catabolism of protein from body stores, Growth hormone

demonstrated a normal semi-starvation response with a large rise from baseline.The large standard deviation in the final sample represents large growth hormone

pulses captured at the time of blood sampling in six of the ten individuals with the

largest FFM losses (Table 23). Serum triiodothyronine (T3) levels declined by 40%,consistent with the normal response in semistarvation to reduce metabolic rate.This reduction is also important during infection. The more potent thyroid hormone,thyroxine (T4), also declined but to a smaller extent (data not shown).

IGF1 (nglmL). T3 (ng/dL) GH (ug/L)200 6

IGF1

175 5175 .... .... ... . Growth hormone (GH)

150 . 4

125 -3

1 07 ...5 I. .... .. .... .. .. . ... . .. . .. . . . . .....

75. Triiodothyronine (M3)1

50 . _. _ _ _ _. 0BL I II III IV

Figure 23. The changes in mean serum levels of IGF-1, growth hormone, andtriiodothyronine reflect normal responses to a prolonged energy deficit.

67

t w +I + I +1 + 1 - () +1

:3 CV) 'q ' r - (V) OD) 0 ) c0 r -

Cq CM N V, CDi C V

0 ) c m V - + 1 + 1 + a l +S+~ +1

C')cr OD ') cC') ~ ~ c~J CuuLr)

CV) )

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00

00

Et r- C - 2e

0 0 0;5e

EOC 0 7S >uv

e2 E E 0

*05. CD cc c I L0 )O(

- c -W n ...a 0 ~ ~ 0 i

DELAYED SKIN HYPERSENSITIVITY TEST

Delayed-type-hypersensitivity (DTH) skin-test reaction is an in vivo test forimmune competence and function of T-lymphocytes and macrophages. A positiveDTH response confirms previous exposure of the individual to the test antigen. Theexposure can be environmental contamination and or prophylactic immunization. DTHskin-test responsiveness of the Ranger students at baseline and upon completion ofthe jungle and desert phases to antigens of 7 microorganisms is presented in Table24. Compared to baseline, the percent number of trainees showing positive DTH skin-test responses to the test antigens tetanus, candida, streptococcus, and tricophytondid not change during the course. Increases v ire found in the percent number oftrainees showing positive DTH skin-test responses to test antigens diphtheria, at theend of the jungle phase, proteus, at the end of both the jungle end desert phases, andtuberculin, at the end of the desert phase. These results demonstrate that T-lymphocyte function in the DTH skin-test reaction is maintained by trainees during theRanger course. In summary, Ranger training does not impair the ability of the traineeto express cellular immunity to infectious microorganisms that they had developedimmunity to prior to the start of training.

Antigen Baseline Jungle Desert

Tetanus 91 87 85

Diphtheria 56a 74b 658,1

Candida 56 56 56Proteus 4 7 a 6 5 b 6 9 b

Streptococcus 24 18 25

Tuberculin 1 6 a 1 6 a 3 1 b

Tricophyton 15 24 15

Percent positive skin-test sites; Inducation > 2 mm In diameter.Values for each antigen marked with unsimilar letters are different

(p< 0,05).

Table 24. Delayed-type-hypersen sitivity skin test responsiveness at baseline andat the end of jungle and desert phases.

69

CELL-MEDIATED IMMUNE FUNCTION

T-lymphocytes are the immune specific cells involved in the DTH reaction.Since it is difficult to evaluate T-lymphocytes individually in the complex in vivo DTHreaction, In vitro tests have been developed to evaluate the function of these cells.T-lymphocytes cultured in vitro undergo proliferation when stimulated with certainlectins, such as pokeweed mitogen (PWM), phytchemagglutinin (PHA) orconcanavalin-A (ConA), or antigens, such as tetanus toxoid (TT), to which theindividual has been immunized.

Proliferative activity in vitro of lymphocytes from trainees at baseline, and upon

completion of Benning, mountain, jungle and desert phases stimulated with PWM,

PHA, Con A, or TT are shown in Figure 24. Compared to baseline, proliferative

responsiveness in vitro of T- and B-lymphocytes to PWM was significantly decreasedin the trainees upon completion of the Benning phase, followed by additional and

equivalent reduction upon completion of the mountain and jungle phases. A partial

recovery, equivalent to Benning phase levels, was observed at the end of the desertphase. Similar results were observed for T-lymphocytes stimulated with PHA-Mi,which primarily stimulates T-lymphocytes. With minor exceptions, proliferative

responsiveness of T-lymphocytes from the trainees to Con A (a T-lymphocytemitogen) was similar to those for T-lymphocytes stimulated with PWM or PHA-M.Regardless of the mitogenic stimulant, T-lymphocyte proliferation was reduced most inthe trainees upon completion of the mountain and jungle phases. Also, T-lymphocyteproliferation was partially (PWM, PHA-M) or fully recovered (ConA) upon completion of

the desert phase. Proliferation of T-lymphocytes to the antigen TT was suppressed in

trainees at the end of the mountain phase, but recovered at the end of the jungle anddesert phases.

The cytokine interleukin-2 (IL-2) is synthesized and secreted primarily byT-helper lymphocytes which have been stimulated with certain mitogens or antigens.

Binding of IL-2 to receptors for IL-2 (IL-2R) induces clonal expansion of antigen-specific T-lymphocytes involved in immune protection against infectious diseases.Release of soluble IL-2R and the production of IL-2 by T-lymphocytes stimulated with

PHA-M from the trainees at baseline, and upon completion of Benning, mountain,

jungle and desert phases are presented in Figure 25a and 25b. Compared tobaseline, IL-2R and IL-2 were significamtly decreased by T-lymphocytes from traineesupon completion of the Benning and mountain phases. I11-2R and IL-2 were fully

70

Percent QuPefcent

S I I I! I I 8 I S S • R I"~

IC,

1 I"°60

IW

,0 Fxj0 0

"i i'O I i bl>

PretI Percent "-

U) Ca

z CL L

O-a

.g ! !! 8 t 8 - lC% X WdoC0& x Vda IE

recovered to baseline level at the end of the jungle phase, and IL-2 was significantlyincreased above baseline upon completion of the desert phase. Similar to IL-2R andIL-2, proliferation of T-lymphocytes stimulated with PHA (Figure 25c) showssuppressed T-lymphocyte function by the Ranger trainees during the course. Thesuppressed T-lyphocyte functions in vitro apl~ar to be primarily due to energy deficit.It also appears that early responses (IL-2R and IL-2) of T-lymphocyteactivation/function normalize quicker to improved energy status than the late response,i.e. proliferation/DNA-synthesis.

The cytokine interleukin-6 (IL-6) is a multifunctional protein produced bylymphoid and non-lymphoid cells. The primary sources of IL-6 from unstimulatedwhole-blood cultures would be T-helper lymphocytes and monocytes/macrophages.These cells plus fibroblasts, hepatocytes, and vascular endothelial cells would be theprimary sources of IL-6 in pla!.ma. Although IL-6 is a muhifunctioilal cytokine it has aMajor rrle in the mediation of the inflammatory and immune responses initiated byintction or Injury. Production oi IL-6 by unstimulated whole-blood cultures iromtrat, eps at baseline, and upon comp:'ton of the Benning, mountain, jungle and desertph&-es are presented in Figure 26. Compared to baseline, whole-blood produced IL-6was significantly decreased in the trainees upon completion of the jungle phase.Co.cAn'rations of IL-6 in cell culture supornatants were lower in trainees upon

cr.rp:etion of the Berining, mountain and desert phases than at baseline, but notsignificantly.

Level" of IL-S in plasma ir trainees at baseline, and upon compleiion of theb..uing, mou.1sin, jungle and desert phases are shown in Figure 26. Compared tobaseline, plasma IL-6 concentrRtion was significantly increased at the end of theBenning phase, followod by O.ignificant decreases at the end of the jungle and desurtphasec. From the Benning through dsert phase the trainees showed continueddecreases in plasma IL-6 at each phase.

In summary, Ranger training had a suppressive effect on cellular functions ofthe immun3 protective system. The suppression was greatest at the time o" highestenergy expenditure and largest energy deficit (end of mountain phase). Thispreceeded the periods of increased incidences of infections Ojungle and desert phases)in the treq,'ees.

72

8a

m

ob

o IL -2R

0 •

I •

-

140

b 12-

10 a

a b3 ýb

4 IL-2

2

0

140 aC

120.

+1 100.b

BLASTOGENESIS

20.

a llne mooning M@uIUIIVI Jun00o Do;*"Figure 25. Changes and recovery of 3 aspects of Ln vitro PHA stimulated Immuneresponse: (a) IL-2 receptor secretion, (b) IL-2 secretion, and (c) proliferation.

73

2SO0-

a2O0- -100

aa-0

60a ui1oo

5000

SUPERNATANT INTERLEUKIN-6 20

0 • - . ,_ ,_ 0

Basein Benning Mountain Jungle Desert

400-120

-1003100 a

-'40C - 60I

100-

PLASMA INTERLEUKIN-

o -0

Saseline Banning *"ntin Jun~gle Desert

Figure 26. Production of IL-6 in unstimulated whole-blood cultures (upper graph) andplasma levels of IL-6 (lower graph), in samples collected through the course.

74

0 o +1 +1

a? 07 Inq

0) t) 0

8 vNý 0

C', 04 0+1 0+1- +1

8 3 S -N

q;I?

r.. 0

00

�,,.I "'c

CONCLUSIONS

The most significant finding in this descriptive study is that aspects of in vitroimmune function are suppressed in the second half of Ranger training. This includesdecreased T-lymphocyte function and suppressed systemic production of interleukin-6.This is the likely reason of increased infection rates during the second half of thecourse. Extensive exposure to pathogens during immersion in the swamps in thejungle phase increases the opportunity for infection and makes this a highlypredictable period of infection risk, especially with respect to cellulitis of the lowerextremities. Prolonged energy deficit is a likely cause of the reduction inimmunocompetence, probably working through other deficits which are likely to includea shortage of proteins important in immune function.

The second most significant finding was the severity of weight loss even thoughmuch of it was represented by diminished fat stores. Based on anecdotal informationand data collected in the 1977 Ranger nutrition study, we expected to see someindividuals lose as much as 10% of their body weight. Instead we found that only 2out of 55 finishers lost 10% of their body weight, with all others losing more. Sincethis includes a few relatively large losses from the muscle mass, this is excessiveweight loss in exchange for the benefit of high stress training. Because the weightloss was so severe, the leanest soldiers in this study were clearly at a disadvantagecompared to their fatter counterparts, an unusual finding for Army training. Comparedto the earlier nutrition study, it indicates that, rather than becoming more lenient, aseach generation of Ranger cadre is likely to claim, the course has becomeincreasi-gly stressful, as the Commander suspected (Appendix I).

Soldiers can be challenged with hunger without producing greater than 10%weight loss and without having to stimulate more profound physiological (endocrine)responses which are triggered to preserve the fat-free mass. This could be producedat a slower rate of weight loss (ie. slightly more food across the course), or with betterfeeding throughout some phases such as the first phase when students are stilllearning basic techniques, or with better feeding in the initial "classroom" portion ofeach phase, when students are being taught instead of evaluated. This latter solutionwould make the course safer as well as more efficient if the lessons are betterretained by students given adequate food (and sleep). The degree of food deprivationmeasured in this study is probably not generalizable to any anticipated modern-daycombat scenarios and combat soldiers pushed to this level would likely find a way tosupplement their diet. However, energy deficits are likely to occur during actual field

77

operations; therefore, future eval jations of ration design and body compositionstandards should acknowledge the importance of body fat reserves in meeting thesedeficits.

A third and very important finding from this study is that even with this amountof weight loss and the restricted availability of rations, the nutritional biochemistryremained so remarkably within normal limits. This included measures reflecting ironstatus and serum proteins. Several of the serum concentrations of vitamins rose frommarginal levels at the start of the course to well within the normal range even asnonsupplementing soldiers continued on one ration/day for half of the time in tilecourse, with samples collected at the end of the periods of restricted rations. Thisattests to the adequacy of the nutrient fortification of Army rations (particularly if thesoldiers are driven to consume all components of the ration, as they were in thisgroup). The measured nutrients, functional status and metabolites all point to theconclusion that Ranger students experience an uncomplicated energy deficit.

The results of this study agree with previous investigations of the influence ofcalorie restriction on health and performance. Restriction of energy intake, whileproviding adequate vitamins and minerals, results primarily in weight loss with somedecrease in function related to muscle strength. The level of energy expenditure atany fixed level of energy restriction will in turn determine the severity and compositionof the weight loss. On the other hand, starvation results in a reduced intake of allnutrients and can lead to a series of serious metabolic and functional changes. Thesituation that we observed during 8-1/2 weeks of Ranger training was consistent withrestriction, but not true starvation. The primary consequences of the level of foodIntake and energy expenditure that we observed In this study were manifested as lossof lean body mass consistent with reduced maximum lift capacity and a possiblecompromise of the defense mechanisms of the immune system.

Unfortunately, the simple solution of a vitamin pill to correct an isolateddeficiency or a second dose of penicillin to fortify the soldiers against infection havenot turned out to provide the anticipated panacea. The best solution is to deal withthe source of the problem, the imposed stressors. This study provides previouslyunavailable quantitative data to predict how much more food must be given for thesame level of energy expenditure (i.e. in a summer class) to reduce the weight loss toaround 10% of body weight. A ormaller energy deficit may also improve immunefunction and lessen the soldiers' risk of Infection and possible medical attrition fromthe course. The reduced weight !oss will also help to moderate the nutritional stress

78

imposed on very lean soldiers by reducing the requirements which force catabolism ofmuscle tissue and, in turn, this will be a benefit to all soldiers completing Rangertraining, in terms of their time to return to pretraining levels of physical strength andconditioning. The approach of limiting weight loss during Ranger training toapproximately 10% will be examined in a 1992 summer class. If an improved Immunestatus is demonstrated with this conservative modification, future changes in the planof instruction and ration requirements in Winter classes can be monitored andadjusted to stay within the 10% limit.

In summary:

o The results of the study suggest that this is an uncomplicated energydeficiency. There was no evidence of a vitamin or mineral deficiency despitereduced rations.

o Weight loss was high but not severe enough to cause long term medicalproblems. It was high enough to produce some loss of muscle mass in nearlyall students, necessitating a post-Ranger period of recovery to original fitnesslevels. The average duration of this recovery has not been defined butrecovery appears to be complete by 6 months after the end of Ranger training.

o Immunological response was compromised, probably due to the reduced planeof nutrition. The decreased T-lymphocyte function and suppressed systemicproduction of interleukin-6 indicate that Ranger students have a decreasedprotection against infectious disease. It is not known if these immune deficitsare continuous during each phase, or if they recover in each phase whenenergy Intake increases.

79

N

RECOMMENDATIONS

o The energy intake should be Increased by approximately 500 kcal/day whenonly one ration per day is scheduled, or by approximately 300-400 kcaVdayover the duration of the course. This will have little to no impact on thechallenging nature of Ranger training but may substantially reduce thephysiological and medical risk consequences. At the same energyexpenditures, this would reduce the average weight loss to less than 10% andmay attenuate the decrements in physical performance and in immune function.This change can be accomplished with minimal alterations to training bysubstituting the Long Life Ration Packet (LLRP; 1570 kcal) ana a pouch breadsupplement (240 kcal) for the MRE ration (1300 kcal).

o The effect of this Intervention should be documented in a follow-on study.

o The nature and speed of recovery of Ranger trainees should be characterizedin a follow-up study in the first 2-3 months following completion of the course.

81

REFERENCES

1. Keys A, Brozek J, Henschel A, Mickelsen 0, Taylor HL: The Biology of HumanStarvation. Minneapolis, MN: The University of Minnesota Press, 1950.

2. Headquarters, Ranger Training Brigade, Memorandum, 7 Aug 91, subject: MedicalSupport Requirements for Ranger Training Brigade (RTB).

3. Riedo FX, Schwartz B, Glono S, Hierholzer J, Ostrofl S, Groover J, Musher D,Martinez L, Brelman R, and the Pneumococcal Pneumonia Study Group:Pneumococcal pneumonia outbreak in a Ranger Training Battalion. Program andAbstracts of the Interscience Conference on Antimicrobial Agents and Chemotherapy,Abstract #48. American Society of Microbiology, 29 Sept 1991, Chicago, IL.

4. Johnson HL, Krzywicki HJ, Canham JE, Skala JH, Daws TA, Nelson RA,Consolazio CF, Waring PP: Evaluation of calorie requirements for ranger training atFort Benning, Georgia. Institute Report No. 34, Letterman Army Institute of Research,Presidio of San Francisco, CA, July 1976.

5. P!eban RJ, Valentine PJ, Penetar DM, Redmond DP, Belenky GL:Characterization of sleep and body composition changes during Ranger training.Military Psychology 1990;2:145-156.

6. Consolazio FC, Matou.h LO, Nelson RA, Harding RS, Canham JE: NutritionSurvey: Ranger Department, Fort Benning, Georgia. Laboratory Report No. 291, USArmy Medical Research and Nutrition Laboratory, Fitzsimmons General Hospital,Denver, CO, January 1966.

7. Hirsch E, Meiselman HL, Popper RD, Smits G, Jezior B, Lichton I, Wenkam N,Burt J, Fox M, McNutt S, Thiele MN, Dirige O" The effects of prolonged feeaing Meal,Ready-to-Eat (MRE) operational rations. Technical Report NATICK/TR-85/035, USArmy Natick Research, Development and Engineering Center, Natick, MA, October1984.

8. US Department of the Army: Combat Field Feeding System - Force DevelopmentTest and Experimentation. Volume 1 - Basic Report. Technical Report CDEC-TR-85-006A. US Army Combat Developments Experimentation Center, Fort Ord, CA,January 1986

9. Askew EW, Munro I, Sharp MA, Siegel S, Popper R, Rose MS, Hoyt RW, MartinJW, Reynolds K, Lieberman HR, Engell D, Shaw CP: Nutritional status and physicaland mental performance of special operations soldiers consuming the Ration,Lightweight or the Meal, Ready-to-Eat military field ration during a 30 day field trainingexercise. Technical Report T7-87, US Army Research Institute of EnvironmentalMedicine, Natick, MA, March 1987.

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10. Cons-,';.) CF, Johnson HI, Nelson RA, Dowdy R, Krzywicki HJ, Daws TA, LowryLK, Wari',, r' P, Calhoun WK, Schwenneker BW, Canham JE: The relationship of dietto the performance of the combat soldier. Minimal calorie intake during combatpatrols in a hot humid environment (Panama). Institute Report No. 76, LettermanArmy Institute of Research, Presidio of San Francisco, CA, October 1979.

11. Crowdy JP, Consolazio CF, Forbes AL, Haisman MF, Worsley DE: The metaboliceffect of a restricted food intake on men working in a tropical environment. HumanNutrition:Applied Nutrition 1982;36:325-344.

12. Headquarters, US Department of the Army: AR 40-25, Nutrition Allowances,Standards, and Education, 15 May 1985, Washington, D.C.: Government PrintingOffice.

13. Lichton IJ, Meyamura JB, McNutt SW: Nutritional evaluation of soldierssubsisting on Meal, Ready-to-Eat operational rations for an extended period: bodymeasurements, hydration, and blood nutrients. American Journal of Clinical Nutrition1988;48:30-37.

14. Opstad PK, Aakvaag A: The effect of high calory diet on hormanal changes inyoung men during prolonged physical strain and sleep deprivation. European Journalof Applied Physiology 1981 ;46:31-39.

15. Opstad PK, Aakvaag A: Decreased serum levels of oestradiol, testosterone andprolactin during prolonged physical strain and sleep deprivation, and the influence of ahigh calory diet. European Journal of Applied Physiology 1982;49:343-348.

16. Rognum TO, Vartdal F, Rodahl K, Opstad PK, Knudsen-Baas 0, Withey WR:Physical and mental performance of soldiers on high- and low energy diets duringprolonged heavy exercise combined with sleep deprivation. Ergonomics 1986;29:859-867.

17. Scrimshaw NS, Taylor CE, Gordon JE: Interactions of nutrition and infection.Monograph 57, World Health Organization, Geneva, 1968.

18. Keusch GT: Nutrition and Infection. In: Current Clinical Topics in InfectiousDiseases (JS Remington, MN Swartz, eds.), New York: McGraw-Hill, 1984.

19. Beisel WR: Single nutrients and immunity. American Journal of Clinical Nutrition1982;35 (suppl):417.

20. Gorse GJ, Messner RL, Stephens ND: Association of malnutrition with

nosocomial infection. Infection Control and Hospital Epidemiology 1989;10:194-203.

21. Bondestam M, Foucard T, Gebre-Medhin M: Serum albumin, retinol-binding

83

protein, thyroxin-binding prealbumin and acute phase reactants as indicators ofundernutrition in children with undue susceptibility to acute infections. ActaPaediatrica Scandinavica 1988;77:94-98.

22. Headquarters, US Department of the Army: FM 21-50, Ranger Training andRanger Operations, January 1962.

23. Headquarters, US Department of the Army: AR 350-15, Army Physical FitnessProgram, 3 November 1989, Washington DC: Government Printing Office.

24. Infantry School, US Department of the Army: SH 21-75, The Ranger CoursePamphlet, September 1989.

25. Headquarters, US Department of the Army: AR 70-25, Use of Volunteers asSubjects of Research, 25 January 1990, Washington DC: Government Printing Office.

26. Gordon CC, Bradtmiller B, Churchill T, Clauser CE, McConville JT, Tebbetts I,Walker RA: 1988 Anthropome-tic survey of U.S. Army personnel: methods andsummary statistics. Natick Technical Report TR-89/044, U.S. Army Natick Research,Development & Engineering Center, Natick, MA, September 1989.

27. Durnin JVGA, J Womersley: Body tat assessed from total body density and itsestimation from skinfold thickness: measurements on 481 men and women aged from16 to 72 years. British Journal of Nutrition 1974;32:77-97.

28. Mazess RB, Barden HS, Bisek JP, Hanson J: Dual-energy x-ray absorptiometryfor total body and regional bone mineral and soft tissue composition. AmericanJournal of Clinical Nutrition 1990;51:1106-1112.

29. Frledl KE, De Luca JP, Marchitelli LJ, Vogel JA: Reliability of body-fat estlma'ionsfrom a four-compartment model using density, body water, and bone mineralmeasurements. American Journal of Clinical Nutrition 1992:55:764-770.

30. Ramos MU, Knapik JJ: Instrumentation and techniques for the measurement ofmuscular strength and endurance in the human body. Technical Report T2-80, USArmy Research Institute of Environmental Medicine, Natick, MA, March 1978.

31. Teves MA, Wright JE, Vogel JA: Performance on selected candidate screeningtest procedures before and after Army basic and advanced individual training.Technical Report T13-85, US Army Research Institute of Environmental Medicine,Natick, MA, June 1985.

32. Schoeller DA: Measurement of energy expenditure in free-living humans by usingdoubly labeled water. Journal of Nutrition 1988;118:1278-1289.

84

33. Schoeller DA, Ravussin E, Shutz Y, Acheson KJ, Baertschi P, Jequier E: Energyexpenditure by doubly labeled water: validation in humans and proposed calculations.American Journal of Physiology 1986;250:R823-R830.

34. Delany JP, Schoeller DA, Hoyt RW, Askew EW, Sharp MA: Field use of D2'6O tomeasure energy expenditure of soldiers at different energy intakes. Journal of AppliedPhysiology 1989;67:1922-1929.

35. Hoyt RW, Jones TE, Stein TP, McAninch G, Lieberman HR, Askew EW,Cymerman A: Doubly labeled water measurement of human energy expenditureduring strenuous exercise. Journal of Applied Physiology 119;71:16-22.

36. Lifson N, McClintock R: Theory of use of the turnover rates of body water for

measuring energy and material balance. Journal of Theoretical Biology 1966;12:46-74.

37. Nagy KA, Costa DP: Water flux in animals: analysis of potential errors in thetritiated water method. American Journal of Physiology 1980;238:R545-R465.

38. Fjeld, C.R., K.H. Brown, D.A. Schoeller. /alidation of the deuterium oxide methodfor measuring average daily milk intake in infants. American Journal of ClinicalNutrition 1988;48:671-679.

39. Rose MS, Carlson DE: Effects of A-Ration meals on body weight duringsustained field operations. Technical Report T2-87, US Army Research Institute ofEnvironmental Medicine, Natick, MA, 1986.

40. Bayoumi RA, Rosalki SB: Evaluation of methods of coenzyme activation oferythrocyte enzymes for detection of deficiency of vitamins B1, B2, and B6. ClinicalChemistry 1976;22:327-335.

41. Vuilleumier RA, Keller HE, Keck E: Clinical chemistry methods for the routineassessment of vitamin status in human populations. Part Ill. The apoenzymestimulation tests for vitamin B1, B2, and B6 adapted to the Cobas-Bio analyzer.International Journal of Vitamin and Nutrition Research 1990;60:126-135.

42. Sauberlich HE: Implications of nutritional status on human biochemistry,physiology and health. Clinical Biochemistry 1984;17:132-142.

43. Lundberg GD, Iverson C, Radulescu G: Now read this: the SI units are here.Journal of the American Medical Association 1986;255:2329-2339.

44. Lennette, EH, Balo.,a, A, Hausler, WJ Jr., Shadomy, HJ. Manual of ClinicalMicrobiology, 4th Edition. American Society for Microbiology, Washington, DC., 1985.

85

45. Gunn BA, Ohashi DK, Gaydos CA, Holt ES: Selective and enhanced recovery ofGroup A and 3 Streptococci from throat cultures with sheep blood agar containingsulfamethoxazole and trimethoprim. J Clin Microbiol 1977;5:650-655.

46. Baker JP, Detsky AS, Wesson DE, Wolman SL, Stewart S, Whitewell J, LangerB, Jeejeebhoy KN: Nutritional assessment - a comparison of clinical judgment andobjective measurements. N Engl J Med 1982;306:969-972

47. SPSS, Inc. SPSSx User's Guide. New York:McGraw-Hill, 1983.

86

APPENDIX I

Statement of the Problem.

Memorandum: Nutution/sleep study--Personal Reflections

COL John J. Maher III

31 January 1992

ATSH-RB (350) 31 January 1992

HMHORANDUH FOR RECORD

SUBJECT, Nutrition/Sleep Study--Personal Reflections

1. In my first three months of command of Ranger TrainingBrigade, I completed my initial assessment of the Ranger Course.with special emphasis on the stress applied to Ranger students.With normal concern for a high attrition course, a seemingincrease in cellulitis and streptococcal cases, and extremelyhigh medical attrition, I took a hard look at the condition ofour Ranger students.

2. The students appeared to be a little more "starved" than Iexpected them to be. When we firmly enforced rules on contra-band (extra food), it seemed that too many students took therisk of getting caught cheating. Were we feeding them enough?In reflection, I considered that the Course had been lengthenedfrom 58 to 68 days, that with a fourth phase (desert), thestudents spent at least eight more days on a field training mealschedule (one a day), and that the HRE (in one of its manyversions since 1983) had less calories than the old "C ration" Ihad in Ranger School. Perhaps we weren't giving students enoughfood, at least not on the summer meal schedule.

3. Given that our Brigade was focusing on converting admin timeto training time within the program of instruction, and thatattrition (especially medical attrition) was so high. I wantedto see if what we fed students was sufficient, in r.rms ofcaloric intake and nutrition. I was concerned that studentsmight need an issued vitamin supplement. I also wanted to knowif they needed a bicillin shot or a "booster" to reduce chanceof infection (if their immune functions were too vulnerable)Lastly, I wanted to recheck the amount of sleep our studentswere getting, and see if the extra sleep given them beforeparachute operations was in fact doing what we thought in termsof safety.

4. In turning over the study to medical specialists, I remindedthem of the purpose of our Course and the necessity of stressingthe students with limited food and sleep. During field trainingexercises, it is extremely important for students to be stressedby a combinatin of constant performance evaluation, fatigue,hunger, and lack of sleep. However severe that stress may be.it must still be "reasonable." As a result (in summary). Iasked the team to assess the condition of the students, tell mewhat was happening to their bodies while in the Course, and give

ATSH-RBSUBJECT, Nutrition/Sleep Study--Personai Reflections

me information which could help me decide how much of whatnutritional or vitamin supplements they needed. I asked them todetermine if immunity was so vulnerable that bicillin or someother drug was necessary. Finally. I requested data on amountof sleep students were recei throughout the Course.

0 /

HM J. MAHER IIIColonel, InfantryCommanding

2

Lm mIm

APPENDIX II

Description of the Ranger Course.

SH 21-75: The Ranger Course Pamphlet

September 1989

Section I. ForewardSection III. The Ranger Course

Section IV (A-F). Student Orientation

THE RANGER COURSE PAMPHLETPROPONENT: ATSH-R DATE: SEPT 1989

El •

SECTION I

FOREWARD

Unit and individual Ranger actions have contributed many courageousand daring exploits to the pages of American history. The story is arecurring one, depicting outstanding leadership coupled with the highestapplication of the skills used in the art of fighting.

Throughout the military history of the United States, Ranger unitshave been formed when needed and have accomplished their purpose with greatcredit. The American Ranger has built on what he inherited from theRangers of the past. The present day Ranger is a man who is assigned tothe 75th Infantry (Ranger) Regiment, the Ranger Training Brigade or is agraduate of the finest and most demanding leadership training in the UnitedStates Army today -- the U.S. Army Ranger Course conducted at Fort Banning,Georgia.

This pamphlet addresses the Ranger Course, a course of instructionwhich develops highly confident, tough and capable small unit leaders. Thecurrent approach to the Ranger Course, training individuals rather thanunits, was initiated in October 1951, when the United States Army InfantrySchool established the Ranger Course at Fort Banning.

The Ranger Course affords the junior leader opportunity, by practicalapplication, to develop and to prove himself in a rugged course of instruction.It is stress-oriented and develops within the Ranger student the ability tolead and command under heavy mental, emotional and physical stress. Theemphasis is on practical, realistic and strenuous field exercises using theInfantry rifle squad and rifle platoon as the training vehicle to accomplishthis development.

The Ranger Course is taught using the most current tactical doctrineaadditionally, emphasis is placed on developing military skills in theplanning and conduct of dismounted, airborne, airmobile and waterbornesquad and platoon-sized operations.

This pamphlet has been designed to acquaint the prospective Rangerstudent with the history of the American Ranger and the Ranger Course.Furthermore, it has been designed to familiarize the commander with thefinal product of the Ranger Course and how he, the commander, can profitwhen his junior leaders earn the coveted United States Army Ranger tab.

2

SECTION III

THE RANGER COURSE

1. GENERAL

The soldier who has experienced combat knows the value of tough,realistic training in leadership and military skills. He knows that hemust be able to successfully accomplish any mission which his unit has beenorganizel, equipped and trained to perform in the shortest possible time,with the least expenditure of resources (men and equipment) and with theleast confusion to maintain a combat effective unit. The Ranger Courseprovides tough, realistic training with a minimum of formal classroominstruction.

2. PURPOSE

The Ranger Course develops the leadership skills of selected maleofficers and enlisted personnel by requiring them to perform effectively assmall unit leaders in a realistic, tactical environment under mental andphysical stress approaching that found in combat. It provides the studentwith practical experience in the application of the tactics and techniquesof Ranger operations in wooded, mountainous, lowland swamp and desertenvironments. Emphasis is placed on development of individual leadershipabilities through the application of the principles of leadership whilefurther developing military skills in the planning and conduct of dismountedinfantry, airborne, air assauAt and amphibious squad and platoon-size combatoperations.

/i ~/.

Ranger students negotiating the log walk/rope drop at Vitory Pond.

1C

3. SCOPE

The Ranger Course is 65 days in length with an average of 19.6 hoursof training each day, 7 days a week. It is divided into 4 phases o+training with each phase being conducted at a different geographicallocation. The first (Benning Phase), 17 days in length, is conducted bythe 4th Battalion, Ranger Training Brigade (RTB) at Fort Benning, Georgia.The second (Mountain Phase), 18 days in length, is conducted by the 5thBattalion, Ranger Training Brigade at Camp Frank D. Merrill nearDahlonega, Georgia. The third (Florida Phase), 16 days in length, isconducted by the 6th Battalion, Ranger Training Brigade at Camp James E.Rudder at Eglin AFB, Florida. The fourth (Desert Phase), 14 days in length,is conducted by the 7th Battalion, Ranger Training Brigade at DugwayProving Ground, Utah. Two days of the course are consumed by maintenance,in/out processing and graduation. Rangers are assigned to one of thethree Ranger Training Companies of the 4th Battalion upon arrival at FortBenning and will be trained by that unit's cadre utilizing Small GroupInstruction (SG6) techniques throughout the phase. Upon rotating throughthe other phases, the same procedures are followed.

The emphasis during the course is on practical, realistic, andstrenuous field training, where the Ranger student will be taughtRanger-related skills based on current tactical doctrine. It is aleadership course for small-unit leaders in which the student is exposedto conditions and situations which closely approximate and often exceedthose he would encounter in combat. Fatigue, hunger, the necessity forquick, sound decisions and the requirement for demonstrating calm, forcefulleadership under conditions of mental and emotional stress are all containedwithin the Ranger Course.

ILI

A Ranger student briefs his subordinates on the route while learning thefunrlamenta's of combat operations.

it

The instruction is conducted with units that vary in size from aninfantry rifle squad to a rifle platoon, in distance traveled from 2 to30 kilometers, and in duration from 1 to 5 days.

The qualified Ranger leader has been trained to effectively leadunder conditions of simulated combat stress. He is evaluated as asmall-unit leader in a series of field training exercises which areconducted primarily at night, under any weather conditions. Live-fireexercises are conducted in the Florida and Desert Phases.Frequent and unexpected enemy contact, reduced sleep, difficultterrain and the constant prwssure of operating within restrictive timelimits all contribute to f.,is atmoshpere of stress.

4. THE BENNING PHASE

The Benning Phe of Ranger training is designed to develop themilitary skills, ihysical and mental endurance, stamina, and confidencea small-unit combat leader must have to successfully accomplish amission. It is also designed to teach the Ranger student to properlymaintain himself, his subordinates, and his equipment under difficultfield conditions during the subsequent phases of Ranger training.However, if the student is not already in TOP PHYSICAL CONDITION when hereports to the Ranger Course, he will have extreme difficulty keeping upwith the fast pace of Ranger training, especially during the initialphase.

The Benning Phase is executed in two parts. The first is conductedin the Harmony Church area and consists of a demanding advanced physicaltraining program and training in the skills necessary to conduct extendedcombat operations. The PT program coisists of runs of 3 to 5 miles,combatives (hand-to-hand combat), and tactical road marches. Advancedphysical training assures physical and mental endurance and the staminarequired for enhancing the basic Ranger characteristics--leadership,confidence and toughness. Technique training includes: map reading,airborne operations, leadership, land navigation, medical considerations,environmental and survival-type training.

The .'cond portion of the Benning phase is conducted at nearby CampWilliam 0. Darby. The emphasis at Camp Darby is on the instruction andexecution of combat operations. The Ranger student receives instructionin the fundamentals of combat operations, to include battle drills,principles and techniques that enable his unit to successfully conductreconnaissance and ambush-type missions. The Ranger will then beafforded the opportunity to demonstrate his expertise through seriesof cadre and student led tactical operations. As a result, the Rangerstudent will gain tactical and technical proficiency, confidence inhimself and be prepared to move to the next phase of the course--therugged Mountain phase.

12

j ,I -

". T I

Ranger students under the watchfuleyes of a Ranger instructor,

Studwnts making combatparachute assault.

5. THE MOUNTAIN PHASE

During the Mountain Phase o' training, the student gains additionaltactical oroficiency in the fundamentals, principles and techniques ofmoploying small combat units in a mountainous environment. He further

develops his ability to lead squad-sized units and to exercise controlthrough the planning, preparation, and execution phases of all

13

types of unit operations, including ambushes and raids, plus environmentaland survival techniques. The Ranger student continues to improve hisability to maintain himself and his equipment for extended periods in thefield with only limited support. The Ranger student becomes aware of hiscapabilities and limitations due to the continuous challenges he encounterson a daily basis from severe weather, rugged terrain, periods of hunger,mental and physical fatigue, as well as emotional stress.

Air Assauit operations at the Mountain Ranger Camp.

Day and night missions are directed against a conventional threatforce. These missions are from two to five days in duration and culminatein a series of combat missions where the unit will infiltrate the threatforward security area, move cross-country over the mountains, cross therapid Toccoa River, conduct night vehicular ambushes, raid threat missilesites, and continue operations in the threat force rear area for an extendedperiod of time. Leadership is tested to the maximum extent, in that anyRanger Student may be appointed at any time to lead tired, hungry Rangerstudents to accomplish the mission.

Student giving operation order.Mountain Phase

14

In addition to his instruction in combat operations and field exercises,the student receives instruction in military mountaineering techniques"which instill a high degree of confidence in himself and his fellowstudents. He learns the fundamentals of rope work, the methods of mountainrappelling, rock climbing, and finally, permanent and semi-permanent ropeinstallations. Party climbing, balance climbing, direct aid climbing, anda 200-foot night rappel on Yonah Mountain culminate the instruction,allowing the Ranger student to fully apply the instructicnn he has receivedin a tactical military mountaineering operation during the Field TrainingExercise (FTX).

Military mountaineering on Moutnt Yonah.

15

At the conclusion of the Mountain Phase, the student moves to the next

phase of training, the Florida Phase, conducted at Eglin AFB, Florida.

S. THE FLCnIDA PHASE

The third phase of Ranger school is at Camp James E. Rudder (AuxiliaryField #6), Eglin AFB, Florida. Emphasis during this phase is to continuethe development of small unit leaders, capable of operating effectivelyunder conditions of extreme mental and physical stress. This will providethe Ranqer strdent with proatical experience in extended platoon leveloperations in a jungle/swamp environment. The training further developsthe students' ability to plan for and lead small units on independent andcoordinated airborne, air assault, amphibious (LCM-B), small boat, anddismounted combat operations in a mid-intensity combat environment againsta well-trained, sophisticated enemy.

Extended platoon operations in the jungle/swamps of the Florida RangerCamp.

Yhe Florida Phase begins by providing the student with a realisticscenario in which the unit has simulated a deployment into a fictitiouscountry. As the scenario develops, the students receive "in-country"technique training that will assist them in accomplishing the tacticalmissions later in the phase. Technique training includes: small boatoperations, expedient stream crossing, employment of AC 130 (SpectreGunship), and techniques of surviving arid operating in a Jungle/swampenvironment.

16

As the technique training is being conducted, the Ranger students are

updated on the sequence of events in the scenario that ultimately will

cause the unit to be co,,mitted to combat. The 8-day FTX is a fast-paced,

highly stressful, challenging exercise where the students are trained and

evaluated on the application of small unit tactics and leadership skills.

To successfully accomplish the missions they receive (raids and ambushes)

the student is required to apply the principles of leadership and combat

techniques learned in the first three phases of Ranger training. The

integration of live-fire training further challenges leadership skills

in a tactically realistic scenario.

Small boat operations.

Ft

414

Stream crossing operations.

17

iI

Amphibious Operations in the Gulf of Mexirco

7. THE DESERT PHASE

Ranger students move to Dugway, Utah for the Desert Phase, the fourthand final phase, by C-141 and C-130 aircraft, under control of the 7thBattalion cadre. In-flight parachute rigging is conducted and airborne Rangerstudents conduct a parachute assault/airfield seizure into the Utah desertsouth of the Great Salt Lake. (Non-airborne Ranger students are air-landed.)In this phase, considered a graduate level of the Ranger Course, theRanger student ancounters a harsh desert environment as well as an aggressiveenemy force. He learns to survive and conserve his energy during theextreme heat uf the summer or cold of winter (temperatures range from 115degrees to - 60 F) through his leadership abilities, and by optimizing thecapabilities of his equipment. He learns to move long distances at nightacross the desert, navigating by terrain features, the compass and stars.Ranger students spend 14 days conducting desert combat operations learningdesert survival skills and conducting force-on-force operations with MILESequipment, live-fire raids and ambushes. The live-fire exercises areconsidered the capstone event for the Ranger student and will furtherdevelop his leadership skills.

Upon completion of the Desert Phase the Ranger students will boardC141/C130 aircraft, conduct in-flight rigging and Jump into Fryar DZ, FortBanning, Georgia. He will graduate two days later if he has met thechallenge and passed all the requirements demanded in the Ranger Course.

18

Operations order prior to move out on a desert combat operation.

S. SUMMARY

High standards are required and maintained in a stressful envircnmentin Ranger training. The Ranger Course produces a man who is a tough andconfident leader who can lead small units under adverse conditions, includingthe effects of extended mental and physical stress, and successfullyaccomplish his mission. He has also proven during the Ranger course thathe can overcome seemingly insurmountable mental and physical challenges.He has demonstrated, while under simulated combat conditions, that he hasacquired the professional skills and techniques necessary to plan, organize,coordinate, and lead a small unit. He has also displayed that he hasmastered basic skills in leadership, dismounted small-unit night operations,demolitions, hand-to-hand combat, low altitude mountaineering, and uniqueinfiltration and *xfiltration techniques via land, air, and sea. As aresult of proving that he can successfully accomplish these tasks duringthe Ranger Course, he is authorized to wear the coveted Ranger tab. Thegraduate of the Ranger Course is the epitome of military competence andefficiency in all Infantry skills.

19

Ranger receiving the coveted "Fanger Tab" duringRanger Class Qraduation ceremony

Ranger Graduation at Todd Field

20

SECTION IV

STUDENT ORIENTATION

A. GENERAL

The following information is intended to answer typical questions forthe prospective Ranger student.

1. The Ranger Training Brigade trains students from all services ofthe United States Armed Forces and many allied countries. No insignia ofran1k is worn by students during the course; all students are addressed as"Ranger".

2. Throughout the course the 'Buddy System" is used to instill aspirit of teamwork and cooperation. Each Ranger student must know hisbuddy*s location and welfare at all times throughout the course.

3. U.S. Army graduates of the Ranger Course are awarded an AdditionalSkill Identifier (ASI) or an MOS suffix letter.

a. Airborne qualified officer graduates are awarded the ASI 5S9airborne qualified enlisted graduates are awarded the MOS letter V.

b. Non-a'rb-rne officer qraduates are awarded the ASI 5R; non-

airborne enlistmd ý: auates are awarded the MOS suffix letter 6.

B. PREREQUISITE'j

1. Officers 'f any branch and noncommissioned officers may apply bysubmitting a DA Form 4187 through their unit. Ranger course applicationsare managed at Department of the Army thrqugh the Army Training RequirementsResource System (ATRRB). Enlisted applicants below the grade of E-5 mustsubmit a request for waiver of NCO grade to the applicant's first 06 Commanderin the Chain of Command. Waiver will include the most recent APFT results,and time served in luadership positions. The request for waiver must beendorsed by the indivilual's company and battalion commander. Approvedwaivers must accompany applications for quotas to the Ranger Course.

2. Individuals must be male and must volunteer for the course.

3. All personnel must poiuva* a mwdýLal examination dated within 18months of their reporting date stating that the applicant is medicallyqualified to attend Ranger School. Record of this must be brought by theindividual when he reports for training. Individuals must bring theirhealth records. Health records must include a statement signed by thecommander verifying that the individual has had a panorex made and can bemade available by the sending unit, if required.

21

4. Army Physical Fitness Test (APFT) and Combat Water Survival Test(CWST). Applicants must take the APFT and CWST within 30 days of application.The APFT and CWST should be administered by a Ranger assigned to that Division/Brigade/Battalion an•d the report of results, signed by him, will accompanythe student when reporting for enrollment. All students will be requiredto take the APFT and CWST upon their arrival to the Ranger Training Brigade.

a. APFT. The APFT will be conducted IAW FM 21-20 with changes. Thestandard, regardless of age, for entrance into the Ranger Course is aminimum of 52 pushups, 62 situps, and the two mile run in running shoes in14 minutes, 54 seconds or less. In addition, applicants must e-ecute 6chin-ups (palms 4acing toward the face).

b. CWST. The CWST consists of three events.

(1) THE 15-METER SWIMs Swim 15 meters with rifle, wearing fatigues,boots, and web equipment (pistol belt, suspenders, two ammunition pouches,two full canteens), without loss of rifle or equipment and without showingunusual signs of fear or panic.

(2? EQJIPMENT REMOVAL: Enter water from poolside. Submerge ardremain under water, discard rifle and remove web equipment (as above),surface, and swim to poolside without showing unusual signs of fear orpanic.

(3) THE 3-METER DROP

5. An applicant to the Ranger Course must demonstrate knowledge and beCERTIFIED by his unit commander in the 37 military entry skills specifiedin Special Information paragraph 4. The Commander's certification mustaccompany the applicant and be turned in during inprocessing. Rangerapplicants are liable for random sample testing at the discretion ofthe Ranger Training Brigade Commander.

6. Enlisted applicants must have a standard score of 90 or higher inaptitude area CO and 18 months or more of active duty service remainingafter the completion of the course.

7. No security clearance is required.

6. No additional obligated service is incurred by active Army

commissioned officers for attending the course.

22

9. Students are not required to be airborne qualified.

10. Failure to bring evidence of completion of prerequisite skillsand requirement- when reporting for the training may result in nonenrollment.

C. SPECIAL INFORMATION

1. The Ranger Program performance statistics 4or the fiscal year 1988showed the highest rate of attritiin occured during the first five days oftraining. During days 1-5, all e• iluations are objective in nature andeXamine prerequisite skill proficiency. In order to better prepare your-self for Ranger School a generic outline of the first five days of RangerSchool is listed below: See Physical Training Standards - Section VI.

a. Day 0 - INPROCESS

(1) Event - APFT. Standards: 52 pushups in 2 minutes; 62 sit-ups in 2 minutes; 2-mile run in 14:54 minutes or less; and 6 chinups, notime limit.

(2) Event - COdST. Standards: 15 memter swim, 3 meter drop

and equipment removal.

(3) Average Sleep: 5 hours.

b. Day 1

(1) Event - Hand-to-Hand Training.

(2) Event - Confidence Test. Standards: Complete low crawl,horizontal ladder, rope climb, vertical climb.

(3) Event - Basic Map Review and Terrain Association.

(4) Event - Road March. Standards: 5 miles in 1 hour and30 minutes.

(5) Event - Medical Consideration Class.

(6) Event - Hand-to-Hand Training.

(7) Average Sleeps 4 hours.

23

c. Day 2

(1) Event - PT. Standards: 5 mile run in 41:15 or lessafter PT IAW'FM 21-20.

(2) Event - Technique Training (Warning Orders/OPORDClasses).

(3) Event Rangers-In-Action Demonstration.

(4) Event - Water Confidence Test. Standards: Logwalk/rope drop and suspension traverse.

(5) Event - Technique Training (Warning Orders/OPORDClasses continued).

(6) Event - Hand-to-Hand Training.

(7) Average Sleep: 4 hours.

d. Day 3

(1) Event - PT. Standards: 3 mile run in 24:15 or lessafter PT IAW FM 21-20.

(2) Event - Day Land Navigation Exam. Standards: Mustfind 4 out of 6 points in 5 hours.

(3) Event - Patrol Base Training.

(4) Event - Night Land Navigation Exam. Standards:Must find 3 out of 4 points in 3 hours.

(5) Average Sleep: 5 hoars.

e. Day 4

(1) Event - PT. Standards: 4 mile run in 32:15 or less.after PT IAW FM 21-20.

(2) Event - Airborne Refresher Traininq.

(3) Event - Conduct Airborne/Assault Operations.

(4) Event - Land Navigation Retest.

(5) Event - Establish Patrol Base/Patrol Base Operations

(6) Average Sleep: 4 hours.

f. Day 5

(1) Event - 4 mile run/5 mile retest.

(2) Event - Operational techniques classes.

24

2. All applicants planning to attend this instruction should bebriefed on the Ranger Course by a Ranger-qualified officer or NCO priorto making application.

3. All Commanders must ensure that applicants are in top physicalcondition when reporting for the Ranger Course. Due to the extremetemperatures and humidity at Fort Benning, Ga., during the summer seasonit is recommended that students take advantage of the zero week offeredfor classes 8 thru 11. They would report on Saturday NLT 1200 hours onthe week prior to their original reporting date. Commander MUST screentheir personnel to ensure that personnel with previous cold weather injuriesnot attend classes 1 thru 5 and those personne: with previous heat injuriesnot attend classes 8 thru 11. Personnel attending those classes withprevious heat or cold weather injuries will be immediately dropped from thecourse and sent back to their home stations. Applicants should concentrateon improving upper body strength and road marching in properly fittedboots, with a full rucksack, for distances up to 15 miles.

4. Tla following 37 tasks are necessary military skills needed forsuccessful completion of the Ranger Course and all applicants should beproficient in each. A certificate of proficiency must be signed by the unitcommander and must accompany each applicant.

(1) "Perform Mouth-to-Mouth Resuscitation"

STP 21-1 (SMCT)Task No: 081-831-1042Ref: FM 21-11

(2) "Put on a Field or Pressure Dressing"

STP 21-1 (SMCT)Task No: 081-831-1016Ref: FM 21-11

(3) "Put on a Tourniquet"

STP 21-1 (SMCT)Task No: 081-831-1017Ref: FM 21-11

(4) "Prevent Shock'

STP 21-1 (SMCT)Task No: 081-831-1005Ref: FM 21-11

(5) "Give First Aiu for Burns"

STP 21-1 (SMCT)Task No: 081-831-1007Refs FM 21-11

25

I I_ ., ,.1

(6) "Call For/Adjust Indirect Fire"

STP 7-11824, SM, July 1985

Task No: 061-283-6003Ref: FM 6-30

TEC Lessons%949-06;-011 1A

949-061-0112A949-061-0113A

(7) "Camouflage Yourself and Your Individual Equipeent"

STP 21-1 (SMCT)Task No: 051-191-i361Refs FM 5-20, TC 5-200. FM 21-75, TEC 937-061-0030-F,

TFC 9 3 7 -061-0031F

(8) "Camouflage Your Defensive Position"

STP 21-1 (SeCT)Task Not 051-202-1363Pef: FM 21-75

FM 5-103

(9) "Select Temoorary FightingQ ositions"

STP 21-1 (SMCT)Taok No: 071-326-0513Ref: FM 21-75

TEC Lessont 010-071-L044F

(1W0 "Construct Individual Fighting Position"

STP 21-1 (SMCT)Task No: 071-326-5703Ref" FM 7-8

TEC Lessonls 040-071-1045 and 1046

(11) "Clear Fields of Fire"

STP 21-1 (8MCT)Task Not 0 7 1 -331-0e52

Ref s FM 7-7FM 7-8

2M

(12, "Use Challenge and Password"

STP 21-1 (SMCT)Task Not 071-331-0801Ref: FM 21-75

FM 22-6

TEC Lessons 935-071-1029F, Counter-Intelligence

(13) "Collect/Report Information - SALUTE"

STP 21-1 (SMCT)Task No: 071-331-0803Refs FM 21-75

TEC Lessons 935-071-1026F

(14) "Conduct Day and Night Surveillance Without the Aid ofElectronic Devices"

STP 21-1 (SMCT)Task Not 071-331-0804Refs FM 21-75

(15) "Operate Radio Set AN/PRC-77"

STP 7-11BI, SMTask Not 113-587-2044Reft TM 11-5280-667-12

TM 11-5820-498-12TB Big 291

(16) "Identify Ter-ain Features on a Map"

STP 21-1 (SMCT)Task Noj 071-329-1001Ref: FM 21-26

TEC Lessons 930-071-0013F930-071-0016F

(17) "Determine the Grid Coordinates of a Point on a MilitaryMap Using the Military Grid Reference System"

STP 21-1 (SMCT)Task Not 071-329-1002Refs FM 21-26

TEC Lessons 930-071-0013FSTA 5-2-12

27

(18) "Determine a Magnetic Azimuth Using a Compass"

STP 21-1 (SMCT)Task Not 071-329-1003Ref: FM 21-26

TEC Lesson: 930-071-0017F

(19) "Determine the Elevation of a Point on the Ground Using aMaps

STP 7-11824, SMTask Nos 071-329-1004Ref: FM 21-26

TEC Lesson: 930-071-0016F

(20) "Determine a Location on the Ground by Terrain Association"

STP 21-1 (SMCT)Task No: 071-329-1005Ref: None

TEC Lessons: 930-071-0018F930-071-0163F

(21) "N.-v.igate from One Position on the Ground to AnotherPoint, Dismounted"

STP 21-1 (SMCT)Task No: 071-329-1006Ref: FM 21-26

TEC Lessons: 930-071-0013F930-071-0016F930-071-0018F930-071-0165F

(22) "Measure Distance on a Map"

STP 21-1 (SMCT)Task No: 071-329-1008Rel: FM 21-26

TEC Lesson: 930-071-0014F

28

(23) "Convert Azimuth (Magnetic or Grid)"

STP 7-11924, SMTask No: 071-329-1009Reft FM 21-26

TC 21-26

TEC Lessons 930-071-0015F

(24) "Determine Azimuths Using a Protractor and Compute BackAzimuths"

STP 7-11B24, SMTask Nos 071-329-1031Reft FM 21-26

TEC Lessons 930-071-0014F

(25) "Orient a Map Using a Compass

STP 7-11B24, SMTask No: 071-329-1011Ref: FM 21-26

(26) "Orient a Map to the Ground by Map-Terrain Association"

STP 21-1 (SMCT)Task Not 071-3290-1012Ref: FM 21-26

(27) "Locate an Unknown Point on a Map or on the Ground byIntersection"

STP 7-11B24, SMTask No: 071-329-1014Refs FM 21-26

TEC Less : 930-071-0019

(28) "Locate an Unknown Point on a Map or on the Ground byResection"

STP 7-11B14, SMTask Nos 071-329-1015Reft FM 21-26

TEC Lessons 930-071-0019

29

f29) "Construct a Nonslectric Demolition Firing Systom"

STP 7-11824, SMTask Not 051-193-1002Ref s FM 5-25

FM 5-34TM 9-1375-213-12

TEC Lessons 946-093-7601F

(30) "Construct an Electric Firing System"

STP 7-11B24, SMTask Not 051-193-1004Ref, FM 5-25

FM 5-34TM 946-093-7602F

TEC Lessons 946-093-7602F

(31) "Install US Firing Devices an Standard Military Explosives"

STP 7-11B24, SMTask Nos 051-193-1010Refs FM 5-25

(32) "Clear Nonelectric Misfire*4

STP 7-11B249 SMTask Not 051-193-2019Ref s FM 5-25

(33) "Clear Electric Mismires"

STP 7-11B24, S1Task Not 051-193-2020Ref s FM 5-25

(34) "Practice Preventive Medicine"

STP 7-1191, SMTask Not 071-329-5303Refs FM 21-10

TEC Lessonss 929-441-0042F929-441-0043F911-441-0034F911-441-0035F

30

(35) "Control Rate and Distribution of Fire"

STP 7-11824, SMTask Not 071-326-5501Ref: FM 7-8

TEC Lesson: 010-071-1057F

(36) "Prepare and Issue an Oral Squad Operation Order"

STP 7-11B24, SMTask No: 071-326-5505Ref: FM 100-5

FM 101-5FC 7-5

(37) NOTE: Volunteers should be able to complete a road marchin accordance with the standards specified in the DA Circular for ExpertInfantryman'* Badge; additional reference: FM 21-18, Foot Marches.

D. STUDENT EVALUATION SYSTEM

1. Leadership Evaluation:

a. Each student will be evaluated on his abilities as a small unitleader on a continuous basis throughout the Ranger course. Leadership willbe evaluated based upon how effectively the student influences his subordinatesand uses available resources in accomplishing all assigned tasks andmissions. Specific requirements are listed below.

b. The following areas will be used in evaluating a student duringthe Ranger course to determine successful completion of the course:

(1) Combat operations/Leadership Evaluation - Each student willbe evaluated at least once in each phase in combat operations/leadershipand must receive a "80" in these evaluations. Of these, at least onecombat operation in the Mountain Phase, one in the Florida Phase and DesertPhase must be passed. One of these graded combat operaticns must be in aprimary leadership position. In order to graduate, a student must maintaina 50 percent pass rate in all graded evaluations.

(2) Skill Evaluations - Each s°udant must receive a "GO" in thetwo events listed below according to the specific standard. Any studentwho receives a "NO (0" in any of the events may be eliminated or recycledimmediately.

I*. Ranger Runs - Each student must successfully complete threeof the four graded runs, one of which is a five mile run that tjUU becompleted to receive a "GO" in this event.

LL. Terrain Navigation - Each student must correctly negotiatethe terrain navigation course in order to receive a "GO" in this event.One retest during the Benning Phase will be allowed. Failure of the retestmay result in termination from the course or recycle.

31

(3) Mountaineering Performance Test - Each student must tiecorrectly at least 8 of 12 knots and pass the Delay test to receive a "00"in this event.

(4) Confidence Test - Each student must successfully accomplisheach of the events listed below. Any student who does not successfullyaccompl "h an event or refuses to attempt it may be eliminated from thecourse immediately.

L, Log Walk/Rope Drop (Banning Phase).

b. Suspension Traverse (Benning Phase).

F. Darby Queen (Banning Phase).

1L 200-foot Night Rappel (60-foot Night Rappel during severe

weather) (Mountain Phase).

(5) Critical Incident Report (CIR) - These reports are established

to provide an additional means of evaluating student performance primarily

in a non-graded position. They reflect both good and bad performance.

They are divided into four categories: major satisfactory, minor satisfactory,

major unsatisfactory and minor unsatisfactory. Three minor CIRs are

equivalent to one major CIR. Any major or minor satisfactory CIR will have

the effect of cancelling a major or minor unsatisfactory CIR, respectively.

Three major or equivalent minor unsatisfactory CIRs could warrant recycle

or relief from the course.

(6) Special Observation Report (8OR) - An unsatisfactory SCR is

4rounds for dismissal. No student with an approved 9CR will be allowed to

progress to the next phase.

(7) Peer Evaluations - Students will receive a Peer Evaluation

at the end of each phase of training. A score of 60% on each peer evaluation

must be attained in order to receive a "G0". Failure to attain a passing

score on 2 of 4 peer evaluations will cause the students academic records

to be reviewed to determine his disposition, i.e., continue in the course,recycle or drop from the course.

(8) Each student will not miss more than 72 hours of training

during the entire Ranger Course.

c. At the end of each of the successive phase* (Denning, Mountain,

Florida and Desert) of the Ranger Course, the battalion chain of command

and the Battalion Commander responsible for the phase will review academic

records to determine eligibility for remaining in the course. The Battalion

Commander will make a recommendation to the Brigade Commander for final

decision on relief, recyce or continuation of any student with substandard

performance. The following guidelines will be used in evaluating students

after each of the respective phases:

32

(1) Banning Phase - 4th Battalion, Ranger Training Brigade

(a) A student must pass all of the following skill evaluations:

La. Ranger Runs.

aS. Terrain Navigation.

3, Confidence Tests.

(b) Each student will attend 75% or more of each of thefollowing instruction:

L1. Combatives.

aS. Technique Training and Cadre Led combat operations.

(c) Each student must successfully negotiate the DarbyQueen, Log Walk/Rope Drop, and the Suspension Traverse.

(d) Academic files of students who have received threemajor or equivalent minor unsatisfactory CIRs will be reviewed by theBattalion Commander to determine their disposition.

(e) Any student who receives an approved unsatisfactory SORwill not be allowed to continue to the Mountain Phase.

(f) Each student must successfully pass the end of phasepeer evaluation.

(2) Mountain Phase - 5th Battalion, Ranger Training Battalion.

(a) A student must pass one leadership evaluation in theMountain Phase.

(b) Each student must demonstrate proficiency in Mountaineeringtechniques.

(c) Each student must successfully negotiate the 200-footnight rappel (80-foot night rappel during severe weather).

(d) Any student who has accumlated three major or equivalentminor unsatisfactory CIRs will have his academic file reviewed by the BattalionCommander to determine the student's disposition.

(e) Any student who receives an approved unsatisfactory SORwill not be allowed to continue to the Florida Phase.

(f) Each student must successfully pass the end of phasepeer evaluation.

33

(3) Florida Phase - 6th Battalion, Ranger Training Brigade.

(a) A student must pass one leadership evaluation in theFlorida Phase.

(b) Any student who has accumulated three major or equivalentminor unsatisfactory CIRs will have his academic files reviewed by theBattalion Commander to determine the student's disposition.

(c) Any student who receives an approved unsatisfactory SORwill not be allowed to continue to the Desert Phase.

(d) Each student must successfully pass the end of phase

peer evaluation.

(4) Desert Phase - 7th Battalion Ranger Training Brigade.

(a) One leadership evaluation must be passed in the DesertPhase.

(b) A student must participate in 80% of the live-fireambush/raid operations.

(c) Any student who has accumulated three major or equivalentminor unsatisfactory CIRs will have his academic 4iles reviewed by theBattalion Commander to determine the student's disposition.

(d) Any student who receives an approved unsatisfactory SORwill not be allowed to graduate.

(e) Each student must successfully pass the end of phasepeer evaluation.

2. Honor Graduates

a. The following prerequisites will be used in selecting the HonorGraduates ior the Ranger Courses

(1) Meet the standards for graduation as described in paragraph1.

(2) Pass all graded lecdership positions.

(3) Pass all peer report%.

(4) Lose no major item of equipment due to negligence.

(5) Have no outstanding unsatisfactory CIRs.

(6) Not be a turnback, other than for compassionate or medicalreasons.

(7) Not have been retested in any skill evaluation.

34

b. The Distinguished Honor Graduate will be the officer andenlisted graduate with the best overall performance as determined bythe academic review board.

c. In the event no student mests the criteria in 2 above, thestudent with the best overall performance will be designated Honor Graduate.There will be no Distinguished Honor Graduate.

d. An academic review board will be convened at the end of theRanger Course to review the records of students who completed all thetraining but failed to meet course standards. This board will also considerand recommend the Distinguished Honor Graduate.

E. DISTINGUISHED HONOR GRADUATES

Since March 1956, the officer and enlisted man displaying the mostoutstanding performance in each Renger Class have been designated asDistinguished Honor Graduates. At graduation exercises, they are presentedwith a Letter of Commendation, signed by the Commandant, USAIS, forwarded toeach Distinguished Honor Graduate ti-augh his commanding officer and made apart of his official records.

F. REQUIRED UNIFORMS AND EQUIPMENT

1. Class A Uniformst There are no Class A uniform requirements forpersonnel while attending the Ranger Course.

2. The following uniforms and equipment are minimum quantities requiredfor all students.

NOTE: Those individuals assigned to units authorized to wear the JungleFatigues can wear them in lieu of the BDUs as indicated below:

ItemWinter Summer

Boots, Combat Leather 2 pr 2 prBoots, Jungle (may be used in lieu of the

combat boots during summer can be worn 0 2 prduring the Florida Phase in winter)

Belt, Black Web with Buckle 2 2Coat, BDU 6 6Cap, BDU 2 2Drawers, Cotton underwear (optional) 7 7Duffle Bag 1 1Eyeglasses (military issue) 2 pr 2 prEyeglasses, retainer band 2 2

35

Uniforms and equipment (Continued)

Item.' uanil~y

it em. Winte Summer

Flashlight (military type) 1 1Gloves, shell leather black (military) 2 pr 2 prID Tags with breakaway chain 2 2ID Card 1 1Insarts, wool glove 2 pr 2 prLong underwear, wool, cotton, or polypropylene 2 pr aName tape (last name) 2 2Running shoes I pr I prSocks, black dress or polypropylene 3 pr 2 prSocks, wool, cushion sole 14 pr 14 prSocks, heavyweight (white) 4 pr 0Sweatband, helmet liner 1 1Sleeping shirt 1 ITrousers, BDU 6 6T-shirts, brown 7 7Army Grey PT Uniform 1 1

NOTE: Individuals can bring and use any type of commercial undergarments(polypropylene, capalene, thermax) during the winter training period.!f the color of these garments is other than Army OD or brown, the garmentwill not be visible when worn. Commercial insulated gloves and boots areNO- AUTHORIZED while attending the Ranger Course.

3. The following non-issue items are required (summer and winter)s

Waterproof matchesPocket size notebookPensPencilsShoe shine kit, consisting of the following items:

2 large cans of black or silicone shoe polish1 shoe brush1 large can of saddle soap

Extra bootlaces (5 pr)Black tape, friction or electrical (2)Batteries, D-Cell (4)Combination padlocks (3)Sewing kit (1)Wristwatch (inexpensive but durable ) (1)Pocket knife (1)Weapons cleaning kit, small arms (1)Shower shoes (1 pr)

36

Non-issue items (Continued)

Waterproof bags (ziplock) (12)Shaving and hygiene kit, consisting of the following items:

1 razor with blades and shaviQ cream1 small mirrorI soap dish and soap1 toothbrush and toothpaste4 large (brown) towels2 small (brown) hand towels2 cans of foot powder1 chapstick1 bottle of insect repellent

NOTE& Contact lenses are not authorized during the Ranger Course

4. The following optional items are highly recommended for Rangerstudents3

Map caseMap markersNylon cord (5-50 type)Penlight with batteriesPlastic map protractorLaundry soap (small box)00 wool *we, oa (Army or USMC type)Large trash bagsExtra small waterproof bags (ziplock)

5. Unauthorized items: Radios, tape recorders, cameras, civilianmagazines, telephone sets, prewritten OPORD or OPORD annex formats,mountaineering equipment, food items not issued by RTB, vitamins, aspirin,over the counter drugs and any type of body supplements are unauthorized ineach phase of training.

6. All uniforms will have all insignia removed except name tag andU.S. Army. Boots should be well broken in prior to beginning course.Jungle boots are not authorized during the winter in the Benning, Mountainor Desert phase of training, however they can be worn during the Florida phase.

7. All other required clothing and equipment will be issued by theRanger training companies. It is not necessary for the student to purchaseequipment on his own other than the items listed above unless he deems itnecessary.

37

I

APPENDIX III

Recommendations of the Committee on Military Nutrition Research,National Academy of Sciences.

A Nutritional Assessmentof

U.S. Army Ranger TrainingClass 11/91

A Brief Report of

The Committee on Military Nutrition Research

Food and Nutrition Board

Institute of Medicine

National Academy of Sciences

to

Major General Richard T. Travis

Commanding General

US. Army. Medical Research and Development Command

March 23, 1992

Produced under grant number DAMD17-92-J-2003 between the National Academy ofSciences and the US. Army Medical Research and Development Command

NOTICLE The project that is the subject of this report was approved by the GoverningBoard of the National Research Council, whose members are drawn from the councilsof the National Academy of Sciences, the. National Academy of Engineering, and theInstitute of Medicine. The members of the committee responsible for the report werechosen for their special competencies and with regard for appropriate balance.

This report has been reviewed by a group other than the authors accordingto procedures approved by a Report Review Committee consisting of members of theNational Academy -f Sciences, the National Academy of Engineering and the Instituteof Medicine.

The Institute of Medicine was crtered in 1970 by the National Academyof Sciences to enlist distinguished members of the &ppropriate professions in theexamination ef policy matters pertaining to the health of the public. In this, the Instituteacts und-:r both the Academy's 1863 congressional charter responsibility to be an advisorto the federal government and its own initiative in identifying issues of medical care,r•search, and education. Dr. Kenneth Shine is President--.dsignate of the Institute oiMedicine.

COMM7TIrEE ON MILrrARY NUTRITION RESEARCH

ROBERT O. NESHMIM, (Chair), Monterey, CaliforniaRICHARD ATKINSON, Department of Internal Medicine, Veterans AdministrationMedical Center, Hampton, VirginiaANDRE BENSADOUN, Division of Nutrition Science, Cornell University, Ithaca, NewYorkWILLIAM EVANS, Human Physiology Division, U.S.Department of Agriculture, HumanNutrition Center on Aging, Tufts University, Boston, MassachusettsJOEL A. GRINMR, Program in Human Nutrition, School of Public Health, Universityof Michigan, Ann ArborEDWARD HORTON, Department of Medicine, University of Vermont, College ofMedicine, BurlingtonRICHARD JANSEN, Department of Food Science ard Human Nutrition, ColoradoState University, Fort CollinsGILBERT LEVEILL4 Nabisco Brands Incorporated, East Hanover, New JerseyJOHN A. MILNER, Department of Nutrition, Pennsylvania State University, StateCollege, PennsylvaniaJOHN VANDERVEEN, Division of Nutrition, Food and Drug Administration,Washington, D.C.ALLISON A. YATES, College of Health and Human Sciences, University of SouthernMississippi, Hattiesburg

Food and Nutrition Board Liaison:JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical CenterHospital, Boston, Massachusetts

Committee on Military Nutrition Research Grant Offieir RepretenCOL E. WAYNE ASKEW, US. Army Research Institute of Environnv .al Medicine,Natick, Massachusetts

StaffBERNADETTE M. MARRIOTr, Program DirectorVALERrE McCADDON BREEN, Project Assistant

FOOD AND NUTRMION BOARD

M.R.C. GREENWOOD (Chair), Office of Graduate Studies, University of California,Davis, California

DONALD B. McCORMICK (Vwe CJair), Department of Biochemistry, EmoryUniversity School of Medicine, Atlanta, Georgia

DeWrrr S. GOODMAN (Vi/e Chair) (deceased),t Iustitutc (.f Human Nutrition,Columbia University, New York, New York

PERRY L ADKISSON,* Department of Entomology, Texas A&M University, CollegeStation, Texas

LINDSAY ALL.EN, Department of Nutritional Sciences, University of Connecticut,Storrs, Connecticut

DENNIS M. BIER, Pediatric Clinical Research Center, Washington University Schoolof Medicine, St. Louis, Missouri

EDWIN L. BIERMANt Division of Metabolism, Endocrinology, and Nutition,University of Washington, Seattle, Washington

MICHAEL P. DOYLE, Department of Food Science and Technology, GeorgiaExperiment Station, University of Georgia, Griffin, Georgia

JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical CenterHospital, Boston, Massachusetts

JOHN W. ERDMAN, Jr., Department of Food Science and Division of NutritionalSciences, College of Agriculture, University of Illinois, Urbana, Illinois

NANCY FOGG-JOHNSON, Consumer Healthcare Division, Miles, Inc, Elkhart,Indiana

CUTBERTO GARZA, Division of Nutritional Sciences, Cornell University, Ithaca, NewYork

K. MICHAEL HAMBIDGE, Department of Pediatrics, University of Colorado MedicalCenter, Denver, Colorado

JANET C. KING, Department of Nutritional Sciences, University of California,Berkeley, Californir

JOHN E. KINSELLA, School of Agriculture and Environmental Sciences, University ofCalifornia, Davis, California

LAURENCE N. KOLONEL, Cancer Center of Hawaii, University of Hawaii, Honolulu,Hawaii

SANFORD A. MILLER, Graduate Studies and Biological Sciences, University of TexasHealth Science Center, San Antonio, Texas

MALDEN C. NESHEIM, Office of the Provost, Cornell University, Ithaca, New YorkROY M. PITKIN (Ex Officio),t Department of Obstetrics and Gynecology, School of

Medicine, University of California, Los Angeles, CaliforniaSTEVE L. TAYLOR (Er Officio), Department of Food Science and Technology,

University of Nebraska, Lincoln, Nebraska

Member, National Academy of Sciences"t Member, Institute of Medicine

StaffCATHERINE E. WOTEKI, DirectorMARCIA S. LEWIS, Administrative AssistantSUSAN M. WYATT, Financial Associate

iii

TAJLE OF CONTEMS

IITRODUCTION AND BACKGROUIND ............................. 1

4 - -a -jmndnateulak . .. . ... . . . . . . . . . . . . . . . . . 1Comurftee on twy Nutrftion Meetin& Februany5-7, 1992 ........... IRehlOr r nizati ......................................... 2

QUES7ION POSED TO THE OOM ........................... 2

SUMMARY•OF SPECIFIC RECOMMENDAnONS ..................... 3

REVIEW AND DISCUSSION OF QUESTIONS ........................ 4

Queston 1 .................................... 4Question ................................................. 5Question 3 ................................................ 1Question 4 ................................................ 14Queston 5........................................ 16

AREAS FOR FUTURE RESEARCHI .............................. 17

CONCLUSION ................................................. 19

Referen ............................................... 20Appendices( -V) .......................................... 21

Iv

INTMODUCrION AND BACKGROUND

At the specific request of the COL Eldon W. Askew, Ph.D., Chie, MilitaryNutrition Division, US. Army Research Institute of Environmental Medicine(USARIEM) the Committee on Military Nutrition Research (CMNR) met inWashington, D.C. on February 5-7, 1992. COL Askew is the Grant OfficerRepresentative of the US. Army Medical Research and Development Command(USAMRDC) for Grant no. DAMD17-92-J.2003 to the National Academy of Sciencesfor support of the Food and Nutrition Board's (FNB) Committee on Military NutritionResearch. The pjja of this meeting was to assist the Army in reviewing andevaluating the results of a research project conducted during the training program forU.S. Army Ranger Class 11/91.

Background Materials

Prior to assembling in Washington, the CMNR (the Committee) reviewed: 1) abackground paper; 2) an information paper; 3) preliminary tables of results; and 4) a listof questions raised by the study. These background materials were provided by COLAskew. Copies of this information plus the meeting agenda, committee roster, lists ofspeakers and guests, and the data tables presented as slides or overheads during themeeting, are appended to this report.

Committee on Military Nutrition Research Meeting, February 5-7, 1992

On February 5, 1992 the CMNR convened at the National Academy of Sciences,Washington, D.C. Due to the nature of the research project, the Committee invited fiveadvisors to attend the meeting to augment their expertise in the areas of energymetabolism, vitamin/mineral nutrition, immunology, and protein metabolism. In addition,a guest scientist who has conducted extensive studies of the Norwegian Ranger TrainingProgram participated in the presentations and subsequent discussion. During themeeting the CMNR viewed a videotape of the Ranger Training Program, and heard apresentation of the goals of Ranger Training, presentations of the research results of thestudy: A Nutritional Assessment of Ranger Training Class 11/91, a report of thepreliminary results of a study conducted by the Walter Reed Army Research Institute(WRAIR) at the Ranger School, and general commentary by the five guest advisors.The nutritional assessment study was conducted by the Military Nutrition Division,USARTEM, in response to a request from COL John J. Maher, III, Commander, RangerTraining Brigade. The CMNR was requested to review the results of the nutritionalassessment study conducted by USARIEM and through their answers to the questionsposed by COL Askew, make recommendations regarding the nutritional health and -wellbeing of Ranger trainees and future areas for research.

I

2 A NU"R/T7ONAL ASSESSMENT OF RANGER TRNVING

On February 6 and 7, 1992 the Committee and their pest advior met inExecutive Session and reviewed the research results in light of the goals and mission ofthe Ranger Training Propsm. The group discussed these materials at length jointly andthen met in smaller groups to draft this report. After the Committee meeting, theCommittee, their advisors, and staff worked together to review and revise subsequentdrafts and omponents of this report. All CMNR members present at the meeting andtheir advisors have seen and approved the report Subsequent to approval of the finaldraft by the Committee and their advisors, in accordance with National Research Councilguidelines, this report was reviewed in confidence by a separate anonymous scientif5creview group. The Committee and advisors have reviewed the anonymous comments ofthis review panel and incorporated their suggestions where appropriate. Staff has thenwritten a letter of response to the reviewers with the final report draft and obtained finalapproval of the report from the review panel. This report is thus a thoughtfullydeveloped presentation that incorporates the scientific opinion of the CMNIR theiradvisors for this project, and the anonymous National Research Council reviewers.

Report Organization

Presented below is a listing of the questions posed to the Committee followed bya summn•ay of the CMNR's recommendations. In the latter part of this report theCommittee specifically address each of the questions posed by COL Askew and includedwith each answer is a general overview and specific recommendations. The reportconcludes with suggestions for areas where future research appears warranted. Allmaterials used by the Committee in their deliberation process are included in theAppendices.

QUESTIONS POSED TO THE COMMiTE

1. Is the change in the nutritional status of Ranger trainees of sufficient magnitude tocompromise their health during Ranger training?

2. Are the changes in nutritional status noted transitory and not cause for undo medicalconcern, or are they severe enough to cause concern for the long-term physical healthof the individual (post-Ranger Training)?

3. Are the immunological changes noted related to the plane of nutrition during RangerTraining or to other (eg. sleep deprivation) stressors?

4. Realizing that food restriction is an integral part of Ranger Training, can thenutritional status (risk) be improved significantly by relatively minor changes in the planeof nutrition?

5. Should Ranger trainees be furnished with multivitamin supplements?

A REPORT OF T7HE COMMITTEE ON MILITARY NUTR1770N RESEL4RCH 3

SUMMARY OF SPECFC RECOMMENDATIONS

In answer to the questions posed above, the Committee deliberated anddeveloped specific answers that are detailed in the sections below. Based on theirdeliberations a summary of the recommendations that arose from answers to thecombined questions are as follows:

During Ranger Tainlmg

* establish a "food doctrine" to prevent excessive weight loss* establish a maximum allowable body weight loss for Ranger Training consistent withArmy guidelines"* review protocols for assuring the health of trainees during the entire training program"* consider modifications to apparel worn by Ranger trainees that will reduce dermalinjuries and inflammation* protocols need to be developed to document the occurrence, timing, severity, andetiology of clinical findings, such as overt infections, dermal injuries and inflammation,and problems related to climate, as well as prescriptions of all medication* apply 1 of the 3 suggested modifications to the feeding program possible byimmediately implementing the use of the Food Packet, Long Range Patrol (Improved)(I.RP)* develop a post-training refeeding and preventive health education presentation withand written materials for the guidance of training program participants

Short term follow-up

"• expanded exit exam for all trainees"* physical exams at 3, 6, 9, and 12 months in the first year post-training that includephysical, clinical and biochemical measurements* during the first 6 months, careful attention to the residual capacities of the Rangers,especially personal motivation, history of infection and illness, weight gain and bodycomposition, ventricular and diaphragmatic muscle function, hydration of lean tissue, andthermoregulatory capabilities

Long term follow-up

* expanded yearly physical exams if possible with a recorded history of major illnesses0 further prospective studies only if warranted* conduct retrospective research study using existing data bases

A General Comment

There was an important question not posed to the CMNR. This question is:

I I

4 A NUTRiTIONAL ASSESSMENT OF RANGER TRAINING

What degree of stress through such stretsors as food deprivation, sleepdeprivation, extremes of environment and physical and mental performance tasks, underthe watchful eyes of evaluators, is necessary to achieve the training objectives?

This question cannot be answered from the data presented and is one that issirely of concern to the Ranger Training Command. The data presented from the studyare useful input to the decision process and can help answer questions about the impactof training on nutritional status, and short term medical and immune function concerns.Longer term evaluations can be achieved by both prospective and retrospective studiesas suggested in the report. Obviously personal motivation of participants is anexceedingly important factor in completing the rigorous Ranger Training Program.Appropriate monitoring of individual trainees is needed to make certain that this highdegree of motivation does not lead to excessive tolerance of conditions that need medicalattention.

The Committee has no knowledge to what extent the attainment of trainingobjectives is achieved. The CMNR encourages the Army to systematically evaluate allaspects of the Ranger Training Program and its components through follow up interviewsconducted immediately after training and a number of years post-training. Suchassessments, if not already in place, would provide direct information to the TrainingProgram about the elements of the training experience that soldiers found were mostbeneficial to their later leadership abilities and performance in combat or during specialoperations.

REVIEW AND DISCUSSION OF QUTIONS

In the following section the five questions posed to the Committee are specificallyanswered. After each answer the CMNR presents an overview of their reasoning andrationale as well as their recommendations as they relate to the question posed.

Question 1: Is the change In the nutritional status of Ranger trainees of sufficientmagnitude to wmpromise their health during Ranger Training?

Answer. Yes. Bled on a median body weight loss of 15.6%, documented infection ratesthat inc-.,•a4 to 25.3% and 24.1% at the end of training (Phases III: Jungle and IV:Desert, respectively), and immune system markers, in the data as presented, there isindication that the health of Ranger trainees is at risk during the later phases of training.Trainee health may also be compromised for a period post-training.

A REPORT OF ThE COMMITTEE ON MILITARY NUTRMION RESE.ARCH 5

Disucsslio and ewmneindatlcs:

The Committee notes that COL Maher should be complimented for his concernregarding the strenuous nature of the Ranger Training Program. The Committee alsoapplauds the efforts of the USARIEM research group to study the issues involved inRange Training.

The Committee recognizes that Ranger Training is an important pert of themilitary training needs of the Armed Forces. Further, that deprivation of food and sleeptogether with high levels of physical performance in extremes of environmentalconditions are essential for the proper training outcome. Also it is recognized that sucha program presents certain inherent health risks that must be balanced against thebenefits derived from this trainin, such as awareness of the impact of nutritionaldeprivation on physical performance, morale and judgement. The strenuous nature ofthe training necessitates careful medical monitoring of participants. The Committeetherefore suggests that there be a review of orotocols for medical monitoring to assurethe health of trainees during the entire traininp progrgm. Such a review should take intoaccount the current knowledge about risk of infection, beat stress, hypothermia, andother seriom health complcan tios that might be anticipated during trainin&

The Committee recognizes that while there has been a long history of success withthe Ranger Program without obvious harm to participants, however there has not beena critical review of the longer term health effects on trainees after they complete or leavetheir trainig. Therefore, it is recommended that a short term foll-uR tud beconducted with a number of graduates of the program to assess the relative level ofhealth problems in Ranger graduates compared to other military personnel. This follow-up study should take into account the type of initial assignment and the environment towhich the individuals have been assigned as well as other factors that may have animpact on recovery and health.

Question 2: Are the changps in nutritonal status noted transitory and sot a camuse forundue medical mncem, or are they oewe enovg to cause concern for the I& termphysical bealth of the individual after Ranger Training?

Answer:. The Committee was impressed by the scope and careful research design of thestudies performed by USARIEM during Ranger Training - despite extremely difficultconditions. In particular, the CMNR recognizes the thoroughness of the researchapproach as exemplified by the effort and careful planning involved in movement andrecalibration of the ,jual energy x.ray absorptiometry equipment to the field sites.However, these stud ci are not sufficient to provide definitive answers to the questionof whether the future health of the Ranger trainee Is affected. The health of each traineewould need to be examined in both the short teIm (weeks to months) as well as the IMn

6 A NUI7?J7ONAL A S (ETOP RANGER IR4INING

= (year) following the completio of trainin&g The Committee recommends that suchstudies bt. considered.

Dinsdom sa ad - tIn~Mdao:

The ahb term cnidlerations after such training Involve the immediate ability ofs Ranger to lead trop in combat and/or speia operatioms. Thi knivdal way findhimself ime stresfu conditions before there has been sufficient time or proper

codtiM to repakr the losse which were incurred during the training conditions. Hereit is important to consider not only the PullreMeP loss of adipose tissue' and much smaller(but perhaps signficat) loss of Iean tissue, but the functional corollaries of such Was.

There is jeed for improved nutritional markers that examine the correlationbetwe~en changesIn body composltion ndilssof aitlclfunctio. Telssof abiltyto

fucinin a combat setfti Incudes many thinp from subtle lass of Judgment toobvou weakness, fatigue, and loss of ehnduace. Ther is substantial evidence that lossof body protein st"'m is not confined to skeletal muscle alone, but is associated with acorrespondinga 4o fventricular, diaphragmatii; and intercostal muscles. The residualcapacities of the lianters at the end of trainin for both ventricular work and work ofsespiraio needs to be exmined. In addition, there is concern about the pGPibl lossof specific protein and also the level of neurotransinittors derived from amino acids asrelated to brain functio under suh stressful conditions which may thus warram furtherfneaffsurement

in the sW tUM it would also be Important to examine the bftdrton of the leant~Ei~ssue It may vary more than predicted under Severe field conditions and thus mayinfluence the calculated changes in body composition This could be approached byutilizng the data from the doubly labelled water to obtain total body water which couldbe compared with the dual energy x-ray absortlomet fvFiP-y- (DEXA) data on bodycomposition.

Finally from the sbortUterm perspective, much emphasis in fte presentations wasplaced on the ciremely high individual motivation that allowved many 10 finish (some tobarely finish) the training course, and, that without this motivation, many of thesucessfu candidates would rnot have completed the course. The C~ommittee cautions thatthe aftereffects of such sustained motivation aNd Performance during Ranger Trainingmay be evidenced In variable functional performance and motivationi over the ensuingdays and weeks post-training. This aspec needs consideration and possible inclusion infuture studies.

'IbWm w" S daag from an average of 14.6% body tat (Ramgp: 5.7 - 26.1%,. a a55) at thebelinlngn of training to an average of 5.8% body fat (Range: 4.4 - 11-9%, a w 55) at the end of training(ace Appa4ix Jvc.).

A REPORT OF THE COMMITTEE ON MILITARY NUTRITION RESEARCH 7

The possible log ttlM health effects of such an extreme loss of body fat arelargely unknown and are an important concern. B-mode imaging ultrasound, magneticresonance imaging (MRI), and bioelectrical impedance techniques might be combinedwith DEXA to obtain further information on the changes that have occurred in muscleand fat and the distrbution of the body fat which is regained post-training.

At present, there is not adequate information about changes in weight ormetabolism during the first year post training. To monitor iozis tem health we proposethat standardized physical examinations should be performed quarterly during the firstyear after training and subsequently at the regular six month intervals for several yearsif results from the first 12 months indicate such a prospective approach is warranted.

In addition, a central question of the Ranger Training Program relates to thefunctional significance of certain nutritional markers such as weight loss. The loss ofimmunocompetence with an increased incidence of clinical infections may representimportant evidence of functional loss as a result of combined nutritional, environmental,and psychologic stress. The impact on the immune system of the high intensity physicalactivity coupled with under-nutrition deserves further exploration. Similarly, the impacton the sympathetic/adrenal system should be more rigorously ascertained, at least on anacute basis as indicated by recent rTciews and commentary in this area (Chrouscs andGold, 1992; Wellnes Lette March, 1992).

It remains to be demonstrated just what proportion of the decreasedimmunoc'.rmpetence is specific to nutritional deprivation, however, it is also importantto examine the problems associated with regulating body heat content in the light ofnutritional deprivation. One of the speakers remarked: "Heat was the enemy early in thecourse and cold became the enemy toward the end of the course." This quotationreferred to the variability in environmental temperature during the eight-week trainingperiod. For Ranger trainees, environmental temperatures may vary greatly dependingon the Phase of training, hence training location in the desert, jungle, or mountains. Inaddition, the extremes of climate in these environments seasonally change dramaticallysund therefore the successive Ranger Training classes may experience widely varyingexternal climates.

This quote is thus equally applicable to the problem faced by individual soldiersin regulating internal body temperature. "Cold as the enemy' at thz. end of RangerTraining was to be expected, in part, as a result of intermittent hyperthermia duringheavy exercise and hypothermia secondary to cold exposure. However it has been shownthat the therinogenic response to a mild cold challenge is progressively lost with weightloss in hospitalized patients. Furthermore, this thermoregulatory deficit with weight losscan be restored with nothing more than partial regain of body weight. Perhaps thisfunctional loss of thermoregulation with progressive weight loss causes the vulnerabilityto hypothermia seen in the later weeks of Ranger Training.

8 A NUTRITIONAL ASSESSMENT OF RANGER TR7INING

The measurement of energy expenditure using doubly labelled water offersobvious advantages for field studies such as Ranger Training. However, certainassumptions are required for the use of this method, that usually include a stable foodintake and hence a stable mid-range respiratory quotient (RO) throughout the period ofthe study. Since this is undoubtedly not possible, special attention needs to be given tothe need for periodic measurements of gas exchange or other approaches to thevariations which might be expected in the RO.

It would also be important to collect •rine aj~m•jhsand estimate dietary proteinintake for periods of two to three days during selected parts of the training. Aknowledge of nitrogen excretion, even if only of urinary nitrogen, would be important ininterpreting the weight loss and fat loss in each phase of training.

One particular aspect deserves commenL The observed small proportion of leantissue loss versus the high proportion of fat loss, gave rise to repeated comments duringthe presentations that the results of the training were primarily those of an energy or acalorie deficit. This may be true only in an overall sense. For example, if one only usesdata on the lean tissue present at the beginning and end of the training and thuscalculates an average daily nitrogen loss, this average loss over time is seen to berelatively modest. However, the nitrogen excretion during certain selected periods oftraining may be much higher than the daily average. If this is true, brief periods ofSnitrogen loss might cripple fast-turnover proteins such as certain of the acutephase proteins and perhaps contribute to the growing vulnerability to infection reportedin the second half of the training course. This supposition is of course, speculative butpotentially relevant.

Question 3: Are the immunological changes noted related to the plane of nutritionduring Ranger Training or to other (eg. sleep deprivation) stressors?

Answer. It is impossible to answer this question with the data now available - eventhough these data are extremely valuable and truly unique. Data emerging from thestudies produced by USARIEM, by WRAIR and by Dr. Per Christian Opstad of Norwayin the more rigorous but shorter deprivation studies on Rangers in that country, are notalways consistent. Between-study differences may be due to differences in length ofstudies, in timing of sampling, degree of caloric restriction and sleep deprivation, andambient temperature. The fact that climatic and other stresses involved during datagathering were not consistent must also be considered. Further, the methodologies ofconducting certain tests, and of the analysis, presentation, and interpretation of datagathered by these three groups, were not always uniform.

Nevertheless, an overall consensus of the data certainly indicates the occurrenceof numerous immunological compromises in the Ranger trainees. These involved T-celland B-cell dysfunctions, and also those of phagocytic cells.

A REPORT OF THE COMMITTEE ON MILITARY NUTRI77ON RESEARCH 9

Discussion and Reemmendations:

The T-cell deficits included variable reductions of delayed dermal hypersensitivityreactions and disturbances of in-vtr T-cell responses to rnitogens. The B-cell deficits(undoubtedly in combination with altered T-cell and antigen-presenting cell functions)resulted in poor antibody responses in both primary and secondary exposure to vaccineantigens. Changes were noted in neutrophil performance of oxidative functions.Changes were noted in the numbers of the various circulating white blood cells.Cytokine measurements in both serum and cell culture fluids are still quite novel, butthey too demonstrated changes that are undoubtedly meaningful, but present)y, thesecytokine data are diffictflt to interdigitate with other data for meaningful interpretation.

In regard to the immunologic profile examined however, there was no assessmentof natural killer (NK) cell activity, nor assessment of the phenotype of important sub-populations of lymphocytes such as CD4, CD8, or CD3/CD56, which might be expectedto be affected by the training. These assesments would have given considerably moreinsight into the effects on the immune system. NK activity has been shorn in severalstudies to be particularly affected by stress (for example, Levy et al., 1991 ab).

There were technical aspects of the processing of the samples that might have hadan impact on the results. After collection, blood specimens were held at ambienttemperatures for over 24 hours. It is quite likely that the measurements obtained wereaffected by such storage prior to separation of cells and plasma. Since environmentalconditions varied substantially during training, the test results may have been affected byshifts in temperature and other parameters for which there was no apparent control. Inaddition, plasma cytoldne assays are often difficult to control for quality under optimalconditions. The results of this project should be interpreted with caution due to thesample processing issues mentioned above. Furthet- iies utilizing better controlprocedures for collection, separation and storage t, saiwvles wotild =-.m important.

It should be notd, that the study concwi-dt on Ranger Training Cla-s 11/91(Appendix lVh.) showed nlo significant reduclin o fi de1-,yed cutaneous hypersensitivi4reactions, whereas the WRAIR study of" Rang&er Training Class 12191 (Appendix VNL)pointed to a depression in such reactivity. It is Uiffuit zo compzre the results directlysince there was less specific data provided at this time from the WRU'R prcjecL Afterthe scientists involved have had the opportunity to more fully analyze the data from bothpiojects (for example, see below), joint discussion of the results would be informative.

I: is also difficult to adequately assess the changes that appear to have occurredwith regard to the in.vitr testing. Analyses performed were entirely based on poolingdata for each time point, rather than using each individual as his own control andutilizing alternative statistical analyses. It is recognized that the presentation to theCMNR was based on preliminary data analysis by the scientific teams. As the analysis

10 A NVJTRflONAL ASSESSMENT OF RANGER TRAINING

of this data progresses with the addition of standard deviations and more extensivestatistical procedures, the results will be more readily interpreted.

Over 50 percent of the Rangers developed infections requiring antibiotictreatment during the USARIEM study. These infections primarily involved the lowerextremity, and included cellulitis of the knees, legs, and feet. In view of the significantnumber of infections of the lower extremities, special attention should be directed toreducing stress on the legs and feet. Examination of procedures for proper design andfitting of the Ranger boot is suggested. A numbing sensation in the toes has long beena recognized problem among soldiers. Limited more specific data on digitalgiaparesthetica of the toes (numbing of the toes) from an Israeli Defense Forces studyindicated that this condition was a neuropraxia related to soldiers adaptation to marchingwith heavy packs (see Appendix IVm.). The CMNR thus suggests that Ranger bootfitting be done in such a manner that gait accommodation to carrying heavy loads isconsidered. In addition, since many of the abrasions that may subsequently lead toinfection apparently occur in the knee area, special padding of the uniform such as kneepads that can be inserted in the uniform may be appropriate. Knee pads that arestrapped on over the pant legs are often uncomfortable, more cumbersome, and henceless likely to be used by the soldier.

In addition, respiratory tract infections were prevalent; the S.pnemnmnia carrierrate was unusually high in this study despite biciilin prophylaxis. The several respiratoryinfections were not adequately characterized in the information provided to theCommittee with regard to etiology. It is quite possible that a substantial proportion ofthese were viral in nature, particularly since other clinical studies have indicated thatdifficulties in handling stress may be associated with increased frequency and morbidityfrom viral respiratory infections, concomitant with depressed NK activity (Levy et aL,1991 Lb). Gastro-intestinal infections have also caused problems in other RangerTraining classes. However, it is currently impossible to identify the exact cause of theseclearly identified impairments in immunological functions and host resistance, i.e. toassign blame to the nutritional losses versus the stress (or any one of the many stressesbeing experienced).

Training-imposed dietary restrictions certainly contributed to losses of body weightand nutrient stores. Arduous physical activity certainly contnibuied to increasedmetabolic demands and high rates of nutrient expenditures. The complex and interactingphysical and emotional stresses certainly altered the hormonal milieu o the body in thesetrainees, with multiple secondary metabolic consequences. And of especially greatimportance, the extreme physical exertion, the multiple minor injuries and intlnamr.toryresponses, and the intercurrent infections could each (alone or in combination) havetriggered acute-phase reactions and cytokine releases.

Acute phase responses, if triggered by the endogenous release of the cytoidnesIL-i, IL.6, and TNF [cachectin), could result in hypermetabolism, accelerated catabolism

A REPORT OF THE COMMIMTEE ON MILITARY NUTRMTMON RESEARCH 11

of somatic body proteins, hormonal changes, extensive metabolic changes in hepatic cells,and a wide variety of nutrient losses. The type of cachexia produced by the acute phaseresporte could Iced to immunological dysfunctions. Cytokine initiated cachexia ishypothesized to be a more important cause of nutritionally-induced immune systemdysfunctions thin simple uncomplicated starvation in adults. The available USARI.Mdata suggest (bit do not prove) that acute phase responses were occurring during theFor; Benning Phasx ',f the Ranger Training Program.

Occurrence of acute phase responses early in the Fort Benning Phase of theUSARIEM study is suggested by early changes in iron-related data. These include thefall in serum iron values, the increase in unsaturation in serum iron binding capacity, andthe increase in serum ferritin values. These changes are all indicative of an IL-I inducedmovemer.t of iron from plasma for te-.nporary sequestration in tissue storage sites. Anincrea.se in BUN also suggests an increased protein-catasolic response (which would notbe observed in uncomplicated starvation), as does the previously discussed hormonaldata.

Additional data to confirm the occurrence (or absence) of an acute phase reactionduring Ranger Training would be desirable in fiture studies. Such data should begathered with appropriate timing to detect poseible abrupt declines in plasma zinc values(as well as those of iron), abrupt declines in plasma free amino acid (especiallyglutainine) valujes a slower increase in terum copper values, and an increase in plasmaconcentrations of the acutc:-phase reacting plasma proteins, such as haptoglobin,C-reactive protein, orosomucoid, and ceruloplasrnin, as examples.

Committee discussions emphasized the need for measurements of circulating free&utamine conc/'ntrations. This would provide an important index of the relativedepletion of this specific amino acid as a consequence of a catabolic response involvingthe breakdown of body proteLi, especially muscle protein.

Additionally, and of special importance to the immunological questions at hand,is the growing body of reports that adequate gluta'nine availability is essential for normalimmune system function. Current data suggests that glutamine repletion reducesmicrobial colonization and the incidence of infection in immunocompromized catabolicpatients.

However, a combination of cytVtine-related catabolic stress coupled withdiet-induced protein-energy malnutritiun consistently leads to a synergistic combinationin which immune system functions and other host defense r 'asures are severelycompromised, and secondary infections are common.

The magnitude of food depiivation in the trainees is well documented by excellentmeasurements of L ody composition and anthropometric findings as well as by losses ofbody weight. The extreme hunger experienced by the trainees consti .tted an important

12 ..1 -JTR/FONAL ASSESSMENT OF RANGER TRAINING

emotional stress - sev%-Aa enough to cause some of them to violate honor coderequirements. However, availabl- immunological data and increased infection ratescannot, at this time, be ascribed solely to nutritional deprivation. Historical evidenceshows that severe starvation alone (in the absence of other stresses or catabolic illnesses)may not be rapidly detrimental to Immune functions, and may not lead to an increasedsusceptibility to infectious illnesses.

Multiple concomitant stresses (purposely imposed on the trainees, and probablynecessary for the military success of the program) include food and sleep deprivation,arduous, prolonged, and at times, dangerous training requirements, and the self-imposeddrive to succeed. These stresses cannot be differentiated by any currently knownhormonal or psychological profile. The presence of such stresses is reflected by thenewly available hormonal data, including those defining changes in serum cortisol,testosterone, and insulin-like growth factor I values. Further, it is impossible todetermine if these stress-compatible hormonal changes were due solely to some singleobserved stress (i.e., sleep deprivation, hunger, the other physical and emotionalvariables, alone or in combination), or if they were concomitant aspects of an acutephase response, or even of protein-calorie malnutrition. More consideration should thusbe placed on the likely influence of psychological stress and the perception of all aspectsof the stress by the trainees. Other studies of the effects of stress on the immune systemhave indicated the importance of the perception of stress and the ability of the individualto handle stressful situations. This might be quite heterogeneous among the trainees.Personality and psychological assessments of stress and its effects on psychometricparameters should thus be seriously considered for fut, re studies.

In regard to attempts to sort out the effects of various variables on theimmunologic parameters, it is worth mentioning that the Office of Naval Research hasrecently been performing detailed studies of the psychological effects of regular basictraining of naval recruits on the immune system. This type of training, although quiteless rigorous and physically stressful, hU been associated with multiple changes inimmunologic function. Insight into such comparative data seems pertinent to the studiesof the Rangers. T'his is also related to plasma bets endorphin which has been shown tocorrelate with stress-related alterations in NK activity.

FutLher researlh du, ing Ranger Training should, ideally, include prospective,controlled studies which will identify the occurrence, duration, and severity of acutephase reactions, should they occur. Data should include several biological indicators ofthe acute phase reactions, as well as measurements of key cytokines and their receptors.Investigative priorities should be clearly established, however, since all studies andadditional data mentioned in this section cannot be accomplished and still meet the goalsof Ranger Training.

Immunological studies, including responses to primary and secondaryimmunization, should be repeated in additional trainee groups. This will broaden the

A REPORT OF THE COMMITTEE ON MILITARY NETRPIMON RESEARCH 13

immunologic data base, and help to certify its consistency, since different Ranger classesexperience different climatic and other stresses during their training cycle.

A standardized protocol involving adequate medical observations is needed todocument the occurrence, timing, severity, and etiology of clinically evident infections,and to correlate with immunologic and nutritional findings.

The data on vitamin and mineral nutrition already obtained is excellent and doesnot need to be repeated. Information on possible changes in Vitamin E, zinc, copper,and selenium must still be gathered.

Other nutritional data, including effects of the training and associated stresses onprotein and amino acid (including glutamine) metabolism, would be helpful. This wouldbe even more important if future studies permitted increased feedings during briefperiods between training phases. Naturally, all these data should include adequate pre-and post-training controls.

Previous prophylactic antibiotic use has been authorized. Additional preventivemeasures should be considered to avoid inflammatory skin lesions, such as padding sewninto uniforms to protect knees, as previously described, and also for pressure point areasof packs and equipment. Drug prophylaxis should be considered to block prostiglandin-related components of the acute phase reaction.

Ranger Training does introduce many biologically important variablesconcomitantly, or in rapid succession. We are therefore dealing with a multifactorialproblem, one in which the individial components may never be fully differntiated.While additional research data will be most useful, _ment stel to avoid or minimizethe immunology-related medical problems encountered during Ranger Training include:

* nutritional augmentation compatible with training requirements (these mayinclude increased intake of calories and/or protein);* improvements in military uniforms to reduce dcrmal injuries andinflammation, in particular, better fitting boots to reduce toe numbness and riskof foot infection and possibly adding foam insert pads to the knee area of trousersused during training;* better surveillance of infection incidence;* judicious use of prophylactic measures to prevent infections; and* possible use of prophylactic agents (i.e., ibuprofen, aspirin) in dosessufficient to minimize prostaglandin-related components of the acute phasereaction without masking symptoms of a developing infection.

14 A NUTRTONAL ASSESSMENT OF RANGER 7PAINJNG

Question 4: RealIzing that food restriction is an integral pert of Ranger Training, canthe nutritiomal status (risk) be improved signifantly by relatively minor chantes in theplane of nutritiou?

Answer:. Yes. The charge to the Committee is to recommend alterations in nutrition thatmight result in a reduction in attrition and decrease nutritional risk. The Committeerecommends that this be accomplished by establishing a "food doctrine".

Discussion and Reeommendat ons:

Critical to answering this question are the two major principles of r amgerTraining:

* Deprive the soldier of sleep and food while pushing him to the maximum of hisendurance. The purpose of this exercise is to show future leaders at what pointthey reach their limit of effective function, aid comnvrsely, at what point theirmen would predictably reach their limit of effective function.

* Creating and maintaining periods of hunger is of critical importance toachieving the desired level of multi-faceted stress on the soldier.

An important aspect of the data presented by the Walter Reed Army Institute ofResearch (WRAIR) study (Appendix IVk.) was that soldiers on field training exercises(FTX) who were given two Meals-Ready to Eat (MREa) per day did not experience thecognitive dysfunction characteristic of the USAPREM study. This suggests the possibilitythat one of the two major principle- of Ranger Training would not be realized withsufficient feeding. Thus the CMNR recommends that, instead of increasing total foodintake, a more specific "food doctrine" be adopted. Just as the Army has a "waterdoctrine", a "food doctrine" ,an be viewed as important for optimal performance. Sucha food doctrine could be incorporated into the Ranger School Operations. This wouldinclude the provision and consumption of adequate energy intake for optimalperformance at times when food is available. It would be put into practice by providingguidelines for acceptable body weight loss during non-field operations and includemaximizing food intake whenever possible during field operations. There is no setallowable body weight loss for prolonged field exercise according to U.S. Army policy,however 3% body weight loss is often used as a guideline. For Ranger Training, theCommittee recommends that the Army establish a specific target for maximum percentbody weight loss. This target would be based on the results of the present study andfuture research on the effects of the degree of weight loss on physical and cognitiveperformance and immunocompetence. The CMNR sujgests a preliminary estimate ofthis target might be in the range of 10-12% body weight loss overall.

In addition to the implementation of a food doctrine, the Committee recommendsreview of the following three potential scenarios for altering the current feeding status

A REPORT OF 77TE COMMITTEE ON MILITARY NUTRITION RESE4RCH 15

of soldiers undergoing Ranger Training. It is expected that these approaches wouldresult in better nutrition and reduction in attrition rate:

* Match intake and ouMu Increase food intake to match energ expenditureduring the non-FIX phases of training (part of the "food doctrine"). Continue tofeed troops one NM during the FIX taining; this is likely to produce thedesirable degree of deprivation during the later phases of training. It is possiblethat approach may not provide the appropriate deprivation early in the FortBenming phase.

9 Short bursts of deprivation. If greater deprivation is desired, it would bepreferable to provide the deprivation in isolated periods of time, followed byperiods of greater intake after periods of FIX training (part of the "fooddoctrine"). Such a scenario should result in less suppression of the immunefunction. It would be accomplished by further reduction of Intake during FIX,perhaps by altering one day of starvation followed by a day of feeding one MRE,for a total period that would last only about 7-8 days. Dr. Opstad hasdemonstrated that Norwegian Rangers can develop cognitive dysfunction withinfive days if they are almost completely deprived of food and sleep. The excessfeeding following the FIX period would be of special importance to restoreimmune function and body weight more rapidly.

* Slightly increase intake vet still have deficit. Increase food intake during FIXtraining either by a moderate increase of 200-300 kcal/day such as by using thenew Food Packet, Long Range Patrol (Improved) (LRP)2 that provides aminimum of 50 grams protein and 1500 kcal or by providing two MREs per day.This level of feeding apparently was implemented during the study conducted byWRAIR that, based on preliminary data presented, indicated a decreased attritionrate compared with previous classes.

Regardless of which alteration might be selected, given the levels of depletion inbody weight and immune function in the USARIEM study, the CMNR is concernedabout the health status of the individual soldier after completion of Ranger Training.Additional steps must be taken to ensure that the soldier is aware of the types of foodsand weight gain that should follow the period of deprivation upon leaving training. It isthe understanding of the Committee that the soldier is returned to his unit, which mayactually, depending on timing, be in a deployment mode. Thus the opportunity for thesoldier to regain lost body weight and immune function may be compromised if the

2 T'he Food Packet, Long Range Patrol (Improved) (LRP) is the new name for the USARIEMresearch and development product: the Long LWfe Ration Packet (LLRP) that was reviewed by theCommittee on Military Nutrition Resecarch in 1991 (Publication IOM-91-03, Institute of Medicine,National Academy of Sciences). Information on the menu compone.,4 and estimated nutrient content areincluded in Appendix PA.

16 A NUTTRITONAL ASSES"?' - " ,F RANGER TRAINING

following tour of duty is in an arena in whicb -its and increased energyexpenditure will predominate. Thus it is u,. .a; the Ranger TrainingProgram include information on specific methoaz , _s• oudy weight, lean body mass,and health status following completion of the tminag. 5Swmh nutrition education wouldInclude information on components in the variots typts of military rations and whichcomponents are critical to achieving the objectives of re pining body weight and healthas quickly as possible.

Question S: Should Raner trium be ltmrlsbed with multivitamin suapplkmeuts?

Answer No, based on current data, significant benefits from the use of vitamin andmineral supplements would not be expected. However, future research may suggest theneed for more specific supplementation and routine assessment of the vitamin/mineralstatus of trainees pre- and post-training through scheduled health exams should beconsidered.

Discussion and RPcomisedatlons:

The Committee recognizes the importance of essential vitamins and minerals inmaintaining good nutritional status. The Military Recommended Dietary Allowances(MRDAs) assure that military rations contain the recommended quantities of thesemicronutrients in the foods consumed by the soldier. Based on this, personnel enteringthe Ranger Training Program are in good nutritional status. During the non-FTXperiods the participants receive rEdequate food resulting in adequate intake of themicronutrients. When in the FIX phase of the training, participants receive one tREfurnishing 1300 kcal and at least 1/3 of the MRDA for micronutients. During this timeenergy expenditure is dramatically incrased

Analysis of indicators for vitamin and iron status provides no evidence of anyimpairment of any biochemical indicators of nutfitional status for these nutrients. Thisis not surprising because the subjects entered the program with adequate reserves. Onewould not expect deficiencies to occur in the short time of one week.

A transitory declih' of serum iron concentrations after the baseline period wasconsidered a stress response. This was further discussed in the earlier section onimmune function. It is considered a result, not a cause of the acute phase reaction.

While ziric analysis was not reported for the participants, the central role of thiselement in immune functions is well recognized. During discussions it was reported thata preliminary analysis of four subjects did not indicate a decline in zinc status at the endof the training. We would not expect that zinc status would decline significantly duringone week of food restriction because of compensatory increases of zinc absorption duringreduced intakes and because participants were consuming at least 1/3 of the MRDA evenduring food restriction, however more data are needed to confirm this hypothesis.

A REPORT OF 771E COMMITTEE ON MILITARY NUTRITION RES4ARCH 17

Several other trace elements (i.e. copper, selenium) are also known to participatein immune reactions. The status of those elements was not measured. Markeddeficiencies would not be expected to develop in the short period of tine of reducedintake, however these could be measure instead of vitamins in subsequent :tudies.

AREAS FOR FUTURE RESEARCH

The USARIEM study provided much valuable data but also raised a number ofimportant questions where more research is needed. Among questions raised are thefollowing:

1) What are the relative effects of food deprivation and sleep deprivation oncompromised immune function and inability to complete the course?

2) Are there any thorl term consequences (< 12 months) of Ranger Training onhealth status, body composition, and physical performance of Ranger trainees?

3) Are there any longjtM consequences (> 12 months up to 25 years) ofRanger Training on health status and body composition of Ranger trainees?

Intervention Study

To answer the first question, ideally, a 2-way factorial design in a single trainingclass would be run. Treatment groups would be 1) adequate sleep, adequate food; 2)adequate sleep, food deprived; 3) sleep deprived, adequate food; and 4) sleep deprived,food deprived. Main effects (sleep, food) and interactions would be statisticallyevaluated with a 2-way Analysis of Variance (ANOVA).

However, the opinion of the CMNR is that it would not be feasible to conductsuch a study in a training environment without compromising the training mission. Weinstead believe that the food issue should be investigated first, as described below. It ispossible that at a subsequent time it may be desirable to examine the issue of the effects

of sleep deprivation stress on immune function and success rate.

In a future class at Fort Benning volunteers could be randomly assigned to twogroups: 1) less food; and 2) more food. The group given less food would follow thefood protocol of the just completed Ranger study. The group provided more food wouldbe allowed full access to food during the short periods between the field exercises andin the initial phase at Fort Benning. In the field exercises these trainees would beprovided with two rather than one MRE per day. The data collected in this study wouldbe essentially the same as that collected in the just completed Ranger study. Lessemphasis could be placed on indicators of vitamin status and more on indication ofimmune function, selected minerals, hormonal status, protein metabolism, and body

18 A NA1UT 7MONAL ASSESSME£r OF R4NGER 7Ro7AI7NG

composton as indicated in the earlier sections of this report (see questions 2 and 3aboe), as well as fbllow-up studies of Rag trainees who were and were n succestn completing the course.

The QiMNR recogozes that important logitical and morale issues are raised bydifferential treatment of trainees If it is not possible to carry out a study as describedabove, we suggest that the study just completed be repeated at the same time of year,but that more food bi supplied as described above. This design is much weaker and theresults will be much less conclusive because the sequence of field exercies would bedifferent, the weather and other environmental factors would be uncontoled a wuldbe the variable presence of infectious disease. It is possible that some of the questionsposed by Ranger Tmrani may be a through carefully designed studies in morecontrolled experimental conditions using the envirmntal chambers at USARIEM.

It is suggested that any future evaluation projects include a systematic collectionof data on mental performance. The addition of structured interviews in which probingquestions are asked to further assess cognitive performance, would provide usefulinformation. This could be done within the current training protocols. Comparisoncould be made with soldiers not undergoing sleep and food deprivation, but assigned tothe same tasks.

Short Term Follow-up

From the results of the USARIEM study It seemed clear that graduates of RangerTraining were in a depleted nutritional and health status. The Committee believes it isimportant to follow-up the graduates in the first year immediately following graduation.At three, six, nine, and twelve months following completion of the course, a completephysical examination should be given, including clinical and biochemical measurements.The blood work should include assessment of immune function and hormonal status.Body composition and physical performance should also be assessed.

Long.Term Follow-up

If analysis of data collected from short term studies of Ranger Training classeindicate a need for further follow-up, consideration should be given to a longer termstudy of several years duration.

Retrmpecve Study

To address Iona4ern effects of Ranger Training in a cost effective manver, itwould also be desirable to carry out an epidemiologic.M1 retrospective study in which allgraduates of Ranger Training for the last 25 years are compared with matched controlswho did not participate in Ranger Training. The needed data could be obtained fromthe medical records and other military data bases that are already in use for

A REPORT OF THE COMMITTEE ON MILITARY NUTRITION RESEARCH 19

retrospective studies of this nature. The questions to be asked would be how the groupscompared in morality, morbidity, body omposition, physical performance, and overallhealth status. The control grmup would naed to be careully matched for as manyvariables as possible other than undergoing Ranger Tnaning. This study couldpotentially ideni the presence of any major, klnterm health risk fac associatedWith RAnge Training.

CONCLUSION

In conclusion the CMNR and their advisors found the questions raised by theRanger nutritional assessment project to be of geat importance. Further studies offerboth improved conduct of Ranger Tranting and may also be of more general clinicalimportance for the care of injured and critically Ill patients. The Committee on MilitaryNutrition Research is pleased to provide these recommendations as part of its ongoingactivities in assisting the Military Nutrition Division of USARIEM.

20 A NTIPJ'IONAL AS SETOF RANGER TRAIViNG

Aa.. (1992) Does exrcise boost I~mWuiy U.C Befkdcy WduMW LWW. Murch,.

(kuawcs, OP. and Godd P.W. (1992. Tbw concept of 1, and -aWsu system disoadm.JAM. 257:-1244-1252

Levy, &M., Fernstromz J., Huat=mn RBS, Whiteade T.L, Lge, J., Wa4d M., andMassouadi m. (1991). Nnktend low nuatwaff kler &Cdladhy and circulating l~eel of

3p-mm beta endorpbin: risk fixtos for Pgdfpctiow dbaese~ Lif Sd. 43:107-116.

Lavy, &M., Heibermn,4 L3., LAP., J., Wh~eside, Ti.., Beedle, M., Heidm. L., andSimons A. (1991). lowk~d natural kiea cel activity, pate, and anvironmentlshea as pnxd~tw of lnfecdus magbiity Has: Immam Ca Gvom* Reg. 10:29-307.

APPENDIX IV

Follow-up Study of Rangers studied in Class 91-11.

Katherine E. Harvey

Deborah Je-X~r

Elaine, L. Christensen

MiUtly Nutrition DivisionU.S. Army Research Institte of Environmental Medicine

NatiC., MA 0176n 5007

Appendix IV. Follow-up Study

INTRODUCTION

Following the analysis of data obta'ned from Ranger Class 91-11 and theprompt response of tha Ranger school to increase the calodc intake of student, it was

decided to obaun followup information on th.9 soldiers who had been studied.Because of the increased ration schedule in aubsequent classes, this grouprepresented a onetime oppertunity to study recovery in a worst case energy deficit

scenario. It was also important to define the state of recovery by 6-months post-

training and to obtain recall data on the types of proboems encountered and of

subjective impressions of the time course to reco, ery in order to generally define theframework for a more detailed follow-up study in a second (follow-on) Ranger study in

Ranger class 92-11. This short-term followup was a!so recommended by the

Committee on Military Nutrition Research of the National Academy of Sciences

(Appendix I) and directed by MG Travis, Commander, US Army Medical Research &Development Command. The followup study was approved as an addendum to theoriginal Ranger protocol and was endorsed by the Commander of the Ranger TrainingBrigade, COL Maher (Figure 1).

METHOOS

0' 1.he 55 finishers from the main study, 24 were active Army subjects, locatedwithin CONUS (or Alaska and Hawaii), who could be reached by phone and were

thought to be available f-ir the followup study, pending unit commander approval. Aletter of invitation and instructions, along with a fund citation for TDY travel, was sent

to each of these 24 individuals. Eight soldiers arrived for the followup study. Theother 16 were deployed in field training exercises (10 soldiers) or placed on alert

status (3 soldiers) at the time of the study (4-6 May 1992); 3 could not be released by

their units for other reasons.

The soldiers who participated in this study came from Ranger units (3), Special

Forces units (2), LRSD units (1), or other Infantry units (2). Three had entered Class

91-11 after waiting 30 days at Fort Benning ("gulag") for class openings. Aithough all

of these soldiers were studied at the end of Ranger training in class 91-11, six of the

eight had recycled the final 2 week phase after the original study before successfully

completing the requirements for the tab. One soldier was returning after having been

medically dropped for an orthopedic injury one year before.

Appendix IV. Follow-up Study 2

L M M I I- - . - - .I, . - . . . , . -.. - - - . - _

ATSH-RB (40-400v) 16 April 1992

MEMORANDUM FOR COMMANDERS, RPNGER TRAINING BATTALIONS

SUBJECT: Followup Btudy a' Soldiers from Ranger Class 11-91

I. The rugged nature of Ranger training, and the historicalrecords of high medical attrition (approxionately 600 medicaldrops per year) justify small changes In Ranger training to makeit an even better', yet safer, program. Given that the coursecontent has been revised and the length of the ccurse expandedover the past several years, one of my irlitial concerns Apon

assuming command, was that the amount oi weight loss In soldiersgoing through Ranger training had become too severe, possibly,affecting both current and future performance andconditioning/recovery.

2. To gain more information in this area, I invited the U.S.Army Rtstarch Institute of Envi nmental Medicine (USARIEM) toconduct a study of Class 11-91 east summer. As a consequence ofthe information obtained from this study, we have made changes inRanger training which make it an equally challenging but a saferprogram. With a very short lead time, USAREIM has now beentasked to perform a 6-month post training followup of these samesoldiers to determine what longer term consequences may exist andto develop an infornational program for soldiers completingRanger training.

3. I know t'•t all of you hevo a lot on your plate, and this isanother short notice task, but your help is needed to completethis important effort. I ask that you favorably consider therelease of the study participants currently in your command toparticipate in this followup study, if it does not conflict withthe soldier's scheduled leave or with any essential training.Furthermore, this is a researcl. study for which participation isvoluntary, with the guarantee that there will be no adverseconsequences to a stIdier who chooses not to participate.USARIEM is requesting your soldier(s) for three days of testing,4-6 May 1992 (enclosures) at their location near Boston,Massachusetts, end they will provide the TDY fund cite.

4. If you hove any questions concerning this study, you mayaddress them to the study project officer at USARIEM, MAJ KarlFriedl, at LSN 256-4875 or to COL E. Wayne Askew, DSN 256-4974.Your assistance Is appreciated.

Encls N J. MAHER IIIas Colonel, Infantry

Commanding

Figure 1. Letter of endorsement from the Commander, Ranger Training Brigade.

Appendix IV. Follow-up Study 3

Each volunteer was given a detailed questionnaire about their eating habits andother factors related to return to pre-Ranger training fitness and habits. Each soldierwas then interviewed by a nutrition expert (K.H. or D.J.) about their questionnaire

responses to obtain missing information or to followup on additional information as

patterns of post-Ranger nutritional habits emerged.

A detailed medical records review was performed along with a completephysical examination of each soldier (LTC Lester Martinez-Lopez, M.D.). Theincremental lift test was performed, exactly as it was performed in the main study andby the same observers (Mr. Peter Frykman & SGT Michael Johnson). Bodycomposition was tested in exactly the same way in which it was performed in the main

study, by the same observer (Mr. H, obert Petrin, anthropometry) and with one of the

same DEXA devices, by an experienced technician (SPC Sherryl Kubel).

A fasted blood sample was also drawn at 0800 h, after the second night

following arrival at Natick. Clinical chemistries, hematocrit, hemoglobin, andtestosterone (as a stress marker) were measured in these samples.

RESULTS & DISCUSSION

The physical examinations and clinical chemistries revealed that these 8

soldiers were all in excellent health. Cholesterol levels had returned to normal levw(average: 152+23 mg/dL)(Figure 2). Erythrocyte and serum markers of vitamin statusand other nutritional and metabolic indicators fell within the normal range for 6 of the

volunteers. Levels of all measured vitamins and ferritin were elevated to or above theupper limit of the normal range in a seventh volunteer who used a range of nutritional

supplements; his cholesterol was well below average (113 mg/dL). The eighthvolunteer, who smoked heavily and acknowledged poor current fitness and eating

habits during the dietary interviews, demonstrated values at the opposite extreme, witha deficiency of Vitamins B6, B12, C and an elevated ferritin and iron, although liverfunction tests and other health indices were completely normal. Serum testosterone

levels which had consistently decreased in response to tht stress of Ranger training

were fully restored to normal levels.

Five of the eight soldiers had encountered toe numbness which persisted for

1-3 months after the end of training, although one soldier still had some toe numbness

Appendix IV. Follow-up Study 4

on one foot (the only one who had not worn jungle boots and wool socks; he woreleather boots with a nylon/wool sock combination). One soldier had scars over the

sacral region from rucksack abrasions which occurred during Ranger training. Fivesoldiers had infections during Ranger training but had no resir'ual complaints at thetime of followup. Seven of the 8 soldiers experienced diarrhea for 3 days to 2 weeksafter the end of training and 5/8 encounteged sleep problems for approximately 1month post-training. Since training, 1 soldier had separated his rifjht shoulder but wasfully recovered; I fractured his left ank!e and had a reduced range of motion in thejoint; I had an overuse injury with calf swelling which had resulted in a 10 dayconvalescent leave and was resolved.

The physical measurements '. ad all returned to pre-training levels.Representative data is shown in Figure 3 (i.ody weight & % body fat), Figure 4(abdominal circumference and suprailiac skinfold), and Figure 5 (fat-free mass &incremental lift performance). These res'. Its indicate that by 6 months post-training,the physical parameters were completely -eturned to normal.

Cholesterol (mg/dL)300

B/L 1 11 111 IV 6M POST

Figure 2. Serum cholesterol levels (following overnight fasting) measured at thebeginning and end of each phase of Ranger class 11-91, and 6 months later.

Appendix IV. Follow-up Study 5

J BOWy WI. (Ibs)

1

START END 6M POST

F~~gur ~ 3 -. Body weig t(upr rah an pecn boyft( wr r h)m~ued t

the..be.inning..and.end.of.Rang..r.cla.s..11..1.and.6.months ..later.

Appendix..... IV .........Sudy.

Abdominal Circumference (cm)

2M HAMGER TIIMI65 Imumm IISTART END 6M POST

40 Suprailiac Skinfold (mm)

30

2i

2M RAMGER TAWG0 ,

START END 6M POST

Figure 4. Abdominal circumference (upper graph) and 0upralliac skinfold thickness (lower

graph) measured at the beginning and end of Ranger class 11-91 and 6 months later.

Appendix IV. Follow-up Study 7

Fat-Fr.. Mass (kq

7 0 .... ..-.. ................ ....

STA END...... ... POST.........

F~~~~~gure ~ ~ ~ ~ ... 5..atfre.mss(upergr.h)an..c.eenallif.pr. rmace(lwergrph

measured 5 atte .einigad.n.f.agr.ls.1.1.n m nh ltr

50en i .......... F..........o....-up.... Study.....8

The results of the questionnaires and interviews are as follows.

Personal prorities - 1st day oost-Ranger training. When asked to rank the 5most important things to do on the first day after Ranger school, 7/8 put eaing in firstplace and 6/8 put sleeping in second place.

Food intakes. Overeating was common to all of the soldiers in the followupstudy and this appeared to be closely associated with diarrhea, cramping, and nausea.After 3-7 days, the Rangers reestablished control of their food intake (Table 1).

Food cravings. Four of the soldiers stated that they did not return to normalfood types and amounts until 1 month after Ranger school, the others all took longer.Food consumption increased over pre-Ranger levels in the first month after trainingwith increased consumption of these foods:

1. (7/8) doughnuts, cookies, cakes, pastries2. (6/8) ice cream

beverages3. (5/8) beef (hamburger, steak), pork

salty snacks (chips, peanuts)4. (4/8) fried foods5. (3/8) chocolate, candy

breads6. (2/8) fruits, vegetables

Thus, the primary increase in consumption was for foods which are high in fats andsugars. Specific individual cravings were for peanut butter, pizza, and chocolate.Table 2 summarizes some specific individual comments.

Eatina out. The soldiers indicated that they had increased their eating in fastfood resturants by > 5 times/week (6/8); most meals were ordinarily eaten at home,with only 2 eating in an Army dining facility and 1 soldier eating primarily In resturants.

Vitamin suoDlements. One Ranger had used a multivitamin throughout Rangerschool and continued to use it. Two used a multivitamin occasionally during training.Seven of the 8 soldiers were not using any vitamin supplements after Ranger school.

Appendix IV. Follow-up Study 9

Table 1. Individual descriptions of food Intake and gastrointestinal complaints.

Ranger A did not try to control his food intake until the month after Ranger school. Hesuffered no gastrointestinal problems.

Ranger B reported eating until he couldn't eat another bite. His *brain kept telling himto eat." He took Turns for indigestion for 2 weeks during the Desert phase layover(awaiting class 12-91). He experienced nausea twice/day for the first 3 days anddiarrhea 8 times/day for 14 days during this layover, and for several days again aftergraduating with class 12-91.

Ranger C did not try to control his food intake; he ate constantly and always had acandy bar in his pocket. He had diarrhea and cramping 4 times/day for 3 wseeksduring the Desert phase layover period. His appetite was almost normal bhforerecycling with class 12-91. Following graduation he tried to control his food intakeafter 1 week.

Ranger D reported overeating and the use )f Turns or Rolaids during the Desertphase lp.yover. He had diarrhea 6 times/&.y for 14 days which he attributed to alactose intolerance and the consumption of mIlk products. Following graduation withclass 12-91, he tried to control his food intake after 3-4 days.

Ranger E reported eating until he was sick. He took Turns for indigestion during theDesert phase layover period. He ate whenever he was hungry; after 2 weeks hisintake started to decrease. He had diarrhea 4 times/day for 14 days in the Desertlayover and to a lesser extent after graduating with class 12-91.

Ranger F reported that "his body said he was full, but his mind said to eat more - sohe ate." He ate constantly for the first month after Ranger school; now he eats 3meals/day with snacks, an increase in meal frequency but a decreased amount permeal, over his previous eating habits. He had diarrhea and cramping for 10-20 daysduring the Desert phase layover and again following graduation with class 12-91.

Ranger G reported that he ate constantly during the first week after Ranger school.He had diarrhea 4 times/day and cramping 2 times/day for 14 days.

Ranger H reported that initially he had a pronounced hunger and consequentovereating which gradually went back to normal. After 3 days he tried to exert somecontro' over his eating habits. He experienced nausea once/day and diarrhea for 3days. . V.....F -..........................

Appendix IV. Follow-up Study 10

Table 2. Individual changes in food consumption and food cravings.

Ranger #1 reported an increased consumption of beef, doughnuts/cookies/pastriessalty foods, ice cream, and chocolate candy, candy or cakes. He had a strong cravingfor chocolate and a "desire" for sweet foods although he normally does not eat muchsweet food. During his adjustment period, he was able to eat a whole cake at onesitting. His cravings lasted for 3 months.

Ranger #2 reported an increased consumption of beef, fried foods, breads, water, andpeanut butter, with cravings of peanut butter, cocoa, and hamburgers. He ate lessthan usual amounts of ice cream and fruits or vegetables.

Ranger #3 reported eating more of all foods. He listed pizza and lasagna as cravings,but stated "I can't really narrow it down - I wanted everything the same." After a 1-1/2months he said that he tried to eat a more healthful diet.

Ranger #4 reported eating more of all foods. He reported craving "chow hall" food,especially breakfast foods, and he stated that he wasn't being served as much as hewanted.

Ranger #5 reported an increased consumption of doughnuts/cookies/cakes/pastries,ice cream, milk, and pizza. He said he ate more of these foods since he wasdeprived of them during Ranger school.

Ranger #6 reported an increased consumption of beef, fried foods,doughnuts/cookies/cakes/pastries, salty snacks, and beer. He reported craving TacoBell tacos, peanut butter, real blueberry pancakes, and biscuits & gravy.

Ranger #7 reported an increased consumption of doughnuts/cookies/cakes/pastries,salty snacks, and ice cream. He reported craving peanut butter, pasta, and pizza. Heate anything he craved.

Ranger #8 reported an incrGdsed consumption of doughnuts/cookies/cakes/pastries,salty snacks, ice cream, chocolate candy, and beverages (orange juice, soda). Foodsreported as cravings were ice cream, all kinds of candy, chocolate, pizza, and chips.The cravings lasted for 3-4 months.

Appendix IV. Follow-up Study 11

Weight regain. All of the soldiers regained lost weight rapidly after Rangertraining; 5/8 gained weight to 10 pounds or more over their normal weight; several ofthese soldiers wanted to lose 5-10 pounds now, but one wanted to gain (see Table 3).In general, the recollections of weight loss were greater than the actual measuredchanges but the initial weights were also remembered to be higher, suggesting thatsome of the soldiers may have lost weight during the Ranger Indoctrination Program(RIP), in their training in the Fort Benning "gulag," or in the one week "zero week"acclimation course just prior to the start of Ranger training and the time when theinitial measurements were made. Conceivably, the true weight loss for these soldierswas even greater than the 15.6% average measured across Ranger training.

Sleep auality & duration. Two Rangers stated that they had interrupted sleep,sleeping lightly and waking frequently for the first month after Ranger school. Fourothers stated that their sleep increased by at least 2 hours/night over pre-Rangerusual sleep patterns for 10 days to several months after training. The remaining 2Rangers reported no problems with sleep and no change over previous patterns.

Physical capacity. Three Rangers reoorted that their scores on the first APFT(Army Physical Fitness Test) after their return from Ranger training were as good aswhen they started Ranger school (scores: 285, 287, 298). The APFT performance ofthe others was worse. They described their physical condition as "generally weaker"and offered descriptors such as "easily winded and tired," "always fatigued," andfeeling "broken down." Three attributed their difficulty to lack of exercise training "dueto laziness" (laziness was not precisely distinguished from "fatigue" or "loss ofmotivation"). For most of the soldiers, this period of poor exercise discipline lasted for2-4 weeks and then old training habits were restored. The time to return to peakcondition was not well defined.

Leave/recovery time. Several of the Rangers wanted to take leave time when theyfirst returned from Ranger school but were immediately returned to duty; 4 hadplanned for leave before Ranger training began but 2 of these were disapprovedbecause of a unit block leave policy and because of a scheduled 130 day unit mission;one who did take a 15 day leave wanted more time but had to return to attend PLDC.Three others wanted leave for recovery time when they returned but were denied it;instead 2 of these ended up with 10-12 day convalescent leaves and 1 was awarded a4-day pass. The eighth Ranger did not ask for leave.

Appendix IV. Follow-up Study 12

Table 3. Individual recollections about weight loss and regain. Weights and weight

loss recorded in the study are given In brackets.

Graduatina with class 11-91:

I. Start: 145 [149] Ibs; usual: 145 Ibs; lost: 20 [20.3) lbs. Gained all the weight plus 10lbs in 14 days after Ranger school. Wanted to keep weight at 160 (i.e. lose only 5Ibs) but now down to 155 lbs [155 Ibs].

II. Start: 170 [165] Ibs; usual: 175 Ibs; lost: 42 [25.2] lbs. Gained 42 lbs lost in 30days. Went up to 10 lbs over weight entered but only 5 lbs over usual weight [Now:172.7 Ibs].

Recvcilna desert ohase in class 12-91:

Ill. Start: 150 [178] Ibs; usual: 155 Ibs; lost: 38 [58.8] lbs. Gained all the weight backby the end of Desert phase layover but lost it again at end of 12-91 Desert phasetraining. Gained the 38 Ibs lost again in 30 days [Now: 153.0 Ibs].

IV. Start: 198 [195] Ibs; usual: 198 Ibs; lost: 40 [28.8] lbs. Gained 40 lbs lost in 21days to "normal weight" [Now: 203.5 Ibs].

V. Start: 160 [153] Ibs; usual: 155 Ibs; lost: 30-35 [25.2] lbs. Gained 50 lbs at the endof 3-1/2 week Desert phase layover. At graduation, still had approximately 10 lbs tolose to return to normal weight [Now: 155.8 Ibs].

VI. Start: 230 [211] Ibs; usual: 215 Ibs; lost: 60 [43.8] lbs. Gained all 60 lbs in 60 days[Now: 214.5 Ibs].

VII. Start: 165 [153] Ibs; usual: 165 Ibs; lost 42 [14.0] lbs. Gained 35 lbs in 9 daysand then continued to gain. Now weighs 175 lbs [167.5 Ibs] and wants to lose 10 lbs.

Viii. Start: 155 [139] Ibs; usual: 145 Ibs; lost: 25-30 [15.5 Ibs]. Gained 47 lbs by theend of 3-1/2 week Desert phase layover. By graduation, 15 lbs over usual weight[Now: 145.2 Ibs].

Perceived and measured weights are given as: "start". beginning of the course;"lost"= weight lost In 8-1/2 weeks of class 11-91.

Appendix IV. Follow-up Study 13

CONCLUSIONS

The findings here are quite similar to those noted in the Minnesota Study,where calorie deprived volunteers became obsessed with food and this carried into therefeeding stage (1). The recollections of these 8 soldiers were consistent with otheranecdotal evidence obtained at the end of the course, where students had packets ofindex cards with listings of favorite resturants and recipes which they had constructedduring the course. At least 2 soldiers in good academic standing had been removedfrom the class in the last phase for food violations: one had walked out of a diningfacility with an orange and the other had ordered pizza while hospitalized for 24 hours.

Contrary to some expectations, there were no apparent residual problems 6months after the end of Ranger training. The soldiers had all returned to normal bodyweights and body composition and there were no apparent medical problems (exceptfor one set of numb toes). The impression of the examining physician was that these8 soldiers were characterized by superb health and fitness.

The problems which these Rangers reported retrospectively occurred primarilywithin the first 2 months after Ranger training, with overeating, diarrhea (probablyrelated to the overeating), sleep disturbances, and reduced physical capacity.

These results indicate that a more detailed study of the post-Ranger trainingrecovery should focus on the first 2 months, should include body composition, physicalperformance, and sleep activity, as well as detailed analysis of eating habits.

ACKNOWLEDGEMENTS

We are indebted to the 8 soldiers who participated in this followup study for theirpatience and cooperation.

REFERENCE

1. Schiele BC, Brozek J. "Experimental neurosis" resulting from semistarvation inman. Psychosomatic Medicine 1948;10:31-50.

Appendix IV. Follow-up Study 14